Columnar cell change/hyperplasia with atypia

Peaches70

As I am gathering my records to send to the PS and BS for a consultation in a few weeks, I reviewed the findings from my biopsies again. Two findings, columnar cell change with atypia and columnar cell hyperplasia with atypia, jumped out at me this time. I had dx of ALH in one breast, LCIS in the other. The above were found in both. I came across one article about this that said that those lesions with atypia are precursors of low-grade DCIS or IDC. No doctor ever mentioned this to me, as their focus was on the other conditions. However, I am wondering if anyone else has had this brought up by a doctor. I don't know that it is significant, given that I am already considered high risk, but I figured I might ask the new BS.

Anne

leaf

Hyperplasia (an increased number of cells that line the lobule or duct) does not put you at higher risk of breast cancer (or the risk is so small its very hard to measure.)  Its the *atypia* that puts you at higher risk.

 I do not think that experts believe that atypia is a *obligate* precursor for cancer.  

Maybe this link helps to define columnar cell hyperplasia WITHOUT atypia. http://surgpathcriteria.stanford.edu/breast/columnar_cell_change/ 

 And this link to columnar cell hyperplasia WITH atypia (AKA flat epithelial hyperplasia) which seems to fall short of ADH or DCIS.  http://surgpathcriteria.stanford.edu/breast/flat_epithelial_atypia/  

I highly highly highly doubt that these are *obligate* precursors for DCIS or IDC.  At least if the Stanford website is correct, it sounds like columnar cell hyperplasia with atypia does NOT meet the criteria for ADH.  LCIS is NOT an obligate precursor for breast cancer.  The VAST MAJORITY of people, even with LCIS do not get breast cancer.

The recent trend in the last few years is a SMALL PORTION of LCIS MAY be a nonobligate precursor - in other words a small portion of LCIS may actually become breast cancer.  This does not change the statistic that, on average, in a population, maybe 15-25% of women with atypical hyperplasia may eventually get breast cancer, and about 30% of women with LCIS will.  And we do not know if women with both LCIS and atypical hyperplasia have an added risk.

 For example, in our little group here, at least both you and I have LCIS and ALH.  (I also have ductal hyperplasia, not atypical, and you have columnar change with atypia.)  I know we are only 2 people, but it sounds like it is not uncommon for LCIS women to also have ALH.  From the scant literature I have seen, I don't see people that have BOTH ALH and LCIS having a hugely increased risk of breast cancer over those with LCIS.  But there haven't been studies done because the numbers are too small. 

Now you may or may not want to get your slides reread to make sure of the diagnosis. (I can't remember if you have already done that, or if you care to do that, or whether it will make a difference.) 

  

BessB

Anne,

The radiologist and my family doc were both concerned when ADH showed up on my mammo.  My original BS was not at all concerned.  "Lets wait and see", he said.  My family doc thought I should go for a second BS opinion since I was already in a high risk group due to other factors.  The second opinion BS gave the same concerns for the diagnosis as the radiologist.  Since this BS was actually going through the retirement process, I was sent to Johns Hopkins.  After the results of genetic testing/counseling were released, it was determined that I would undergo a bi-lateral w/immediate reconstruction.  For me, a diagnosis of atypical ductal hyperplasia, multiple foci of atypia and the presence of histological calcifications and columnar cell hyperplasia with atypia, indicated a very high risk. So, I guess what I am trying to say is that it may depend on the "other" risk factors in a women's life as to how high a risk breast cancer is when the compilation includes ADH.    

leaf

This is what a pathology outline says about flat epithelial hyperplasia of the breast (AKA columnar cell change with atypia).

 http://www.pathologyoutlines.com/breast.html#flatepithelialatypia

I certainly don't know how they come up with risk factor estimates.

Ked1019

Anne, while I have not had a dx of LCIS I have been faced with the following:

 CCC w/ Atypia (columnar cell change w/ atypia) basically is a cell that is not normal, when you add the hyperplasia it means many cell layers w/ atypia (not normal). These fall short of ADH which starts to have architectural changes that mimic DCIS but fall a little short of it. Some pathologists will see ADH and not be quite sure and dx the tissue as DCIS. I had my tissues examined 2 x and ended up with Flat epithelial atypia and then CCC w/ hyperplasia and atypia. On open excision they found ALH which was borderline LCIS. When I asked if we should have the tissue sent for 2nd opinion my doctor said no because whether it is LCIS or ALH is a moot point because both increase your risk and neither require any "surgical" or "chemo/rad" treatment. I have been asked to go on Tamoxifen and will have 6 month mam/us and mri testing. The tamox I cannot do at this time due to blood clotting issues.

 I have read and reread all the articles that leaf has mentioned. I do have one that was in a recent  journal that is not published on line but rather I had to pay for it. If you would like it please pm me your email and I will send it to you. I tried the cut/paste article to pm you but I couldn't do it.

 To me I see all of this "crap" that they have found as a precursor/risk or whatever else you want to say it is. To me it means that I need to be on top of it and not go past 6 months w/out tests and I must do my monthly exams. 

 I am not sure if I have answered your questions so sorry if I haven't. I have read too many journals and studies that say many different things and then some similar things. I do know it is important to look at the dates because some of the abstracts/journals build on one another. Please feel free to pm me and we can chat and I send send you the article I have.

 KED

Katy048

Hi everyone,

I have found out to have a group of calcification on my right breast.  A pathologist asked me to have core needle biopsy and the result was columnar cell hyperplasia with atypia.  They recommended me to have excisional biopsy to evaluate adjacent breast tissue in this area.  I was scheduled to have biopsy on Sept. 19, 2008.  The surgeon told me that if it's only columnar cell hyperplasia with atypia, it's done, then keep 6 months mammogram.  Otherwise, radiation will be followed.  Do you folks have any idea how many percentage it will be cancerous? 50, 50 or more?  Waiting and worrying is so hard.  If you could tell me your full story, I will much appreciate.  Thank you.

Anonymous

I've read the incidence of finding something more serious than atypia (ie---in-situ or invasive bc) is less than 30%, so your chances of it being nothing more serious are good---70% is a big # --hold onto that!!!!  If it remains atypia only, just be vigilant with your mammos and breast exams. If it is something more serious, you will deal with that as it comes.  Praying for good results soon.

Anne

Katy048

Hi Anne,

 Thanks for your info.  I hope I will be one of the 70 %. Is it people have hyperplasia with atypia sooner or later will have breast cancer?  Or only have high risk?  

Katy 

turnberry

Hi Anne,

I too had a core biopsy and surgical biopsy last year for the same exact thing.  CCC hyperplasia with atypia.  I also have a family history of bc.  My doctor said this had increased my chances of bc by 5X the normal person (w/o the family history).  My biopsies were also because of calcs.  This was last Sept 07.  Went back in for 6 month followup and it appears that there are more calcs, however they wanted to wait for another 6 month check before doing anything to see if there were any significant changes from that mammo to the next.  I go back in this October for that follow-up.  My surgeon had just told me that if it does become a cancer they want to catch it before it became invasive.  I think that the "majority" of breast cancers tend to grow slowly so that is why the 6 month follow ups.

I have to admit it is a pain going thru the constant follow-ups and waiting.  I think that if I have to go thru another biopsy in October I will probably start the genetic testing depending on the results.  Is that something that you've considered?

Good luck to you and keep us posted.   

Katy048

Hi leaf,

I wouldn't get into the link you have given on your message(with"atypia") on June 29, 2008.  Please check it out.

Thanks, Katy

TheQu33n

Katy, the link is valid, I was able to get there just now. To answer your earlier question, atypia heightens risk,  it does not necessarily grow into cancer. Wishing you the best on your biopsy. karen

Katy048

Hi Karen,

I can get into the link now.  Thank you. One more question,  for excisional biopsy, is it will cut out the whole thing or only a bigger portion of it?  I want to cut out the whole thing since I am afraid it will become cancerous in the future.  Katy

leaf

I can tell you how it was for my excisional biopsy for a core biopsy of LCIS.  They do an excisional (though it IS optional) because about 20% of the time after people get a core biopsy of LCIS and nothing worse, they actually have DCIS or invasive bc nearby.

For LCIS, it is often multifocal and bilateral.  That means that there are often more than 1 spot of it in the breast, and it is often in both breasts.  Often LCIS occurs not at, but near a 'lesion of suspicion'.  Since LCIS and atypia are not usually detectable on any kind of imaging or by clinical exam, the only way they have of getting a diagnosis is by biopsy.

They know this information about LCIS because before about the mid-1990s, they used to routinely do bilateral mastectomies for LCIS, and they could look at the mastectomy specimens. Now many surgeons are reluctant to do this because for early stage invasive breast cancer often one option is lumpectomy + radiation.  

The point of this is : short of giving you bilateral mastectomies, they don't know macroscopically where you have atypia (except in the area that was previously biopsied.)  For an excisional biopsy, they will look at the tissue, and excise around the area.  If they see abnormal tissue, or things like pulling, they will go further.

Of course, no one wants to have cancer.  Most people who have anything suspicious wants anything suspicious to be out.  But unless you have a dreadful family history, I would be surprised if many breast surgeons would do bilateral mastectomies on someone with atypia only. My breast surgeon won't do bilateral mastecomies on me with LCIS. (I have a weak family history.) 

Katy048

Hi leaf, thank you for your explaining details.  I think since I only have a small problem area, it's easy to remove it all out one time.  If the surgeon just cut a bigger portion of it during this biopsy, and the result is cancerous, therefore, they need to do another surgical biopsy to remove the rest of it.  It's not make sense.  I hope you understand what I am thinking.  Katy

leaf

Yes you are right.  What happens is when they remove tissue during the excisional biopsy, they ink it with different colors to show its orientation in the breast.  Then they embed it (I think usually in plastic) so it can be sliced into very fine slices thin enough to look at under the microscope.  They then look and see if they find any cancer or abnormalities.

They generally do the following if they find you have DCIS or invasive cancer.   

If they find cancer in there, then they can give you a diagnosis of cancer.  If they find cancer near the edge, or certainly at the edge, of the sample, then they call this 'dirty margins'.   Then they can go in again and do another excision, or a mastectomy.

They don't worry about margins for LCIS, or any atypia, because there are often multiple spots of it.  Also, LCIS puts both breasts at  higher risk, even if there is only one spot of it in one breast.  Its a strange condition. 

Katy048

Hi Leaf, I totally understanding what you meant.  Thanks, Katy

musicamyl

I already have IDC in my right breast 1.7cm tumor and have a lumpectomy scheduled for 9/23. Today I received results of an MRI-guided biopsy on another 5mm spot that was caught on an earlier MRI but did not show up on the mammogram. The pathology report says:

1. Focal Columnar Cell Change with Atypia

2. Focal Ductal Epithelial Atypia, Favor Reactive.

I am trying to understand what this means and if this is something that will also need to be removed.

Beth1128

hi..I have been dx w/atypica ductal hyperplasia ..flat epitheial and Im going in also on the 23rd for a re-excision because the margins were not clean...I know the first path report of mine some of the pathologist said cancer (DCIS) and some said borderline so it went out for 2nd opinion that one from Yale and came back that the margins were not clean ...I hope this helped...

Beth1128

Leaf...I know you are very knowledgeable in this area and was just curious since I really dont even know what to say I have..either DCIS or "Borderline" but they are going back in for a re-excision on me because the margins were not clean so do u think they are treating it as DCIS because its borderline? THanks in advance for any input..Beth

leaf

Its good to get 2nd opinions on ADH- glad you got one from Yale (a prominent place.)  That's because ADH (atypical ductal hyperplasia) is treated differently from DCIS.  

(They normally don't give rads/mastectomy for ADH.  I thought the usual for DCIS is either lumpectomy+ rads or mastectomy for DCIS.  *NOTE*: I'm not a DCIS expert.  Bessie, among others, knows a lot more about DCIS.)  I do have ductal hyperplasia, but its not atypical.

If I was in your shoes, I would really want this re-excised.  The reason is not that they are treating this like DCIS, but because sometimes they find 'something worse' in the vicinity when they re-excise (different studies differ, but I would guess maybe 10-30%?? of the time they find something worse - ie DCIS or invasive), and since you had some controversy about your pathology already - I'd really want re-excision. 

Beth1128

Thanks Leaf...yes Im going in on Tues for the re-excision...I read alot and to be honest just hearing the margins werent clean I def. have no qualms about going back for a re-excision ..thanks SOOO much for your input Beth

Beth1128

PS...do you think I should have a 2nd opinion again on this report?? Im ASSuming they will send this out to pathology also and I think it would be a good idea to send it to Yale again ....do you think that will be automatic or would I have to suggest it? not sure how that works ..thanks again

Ked1019

Beth1128, thinking of you this week. I hope your path comes back just ADH. I start my journey all over again next month... MRI mam/us etc. I also meet with the onc to discuss tamoxifen. I am not sold on that one yet.

 Email me (at home) and let me know how you do and what the results are. I am having surgery on Friday so I may not be on the computer for several days. I will check as soon as I can though. Sending prayers your way sweetie.

Karen

leaf

If the report comes back invasive, then you may not need a 2nd opinion.  I've heard that its usually quite easy to tell invasive from in situ (except *maybe* when cells get distorted like they can with a fine needle biopsy, but you are NOT having that.)

If it comes back DCIS or ADH, then you may want a 2nd opinion if they don't send it out themselves. If you just get more ADH, then if it was me, I'd  definitely want a 2nd opinion to make sure it isn't DCIS.  

A 2nd opinion is NOT automatic.  I do NOT have ADH or DCIS. I had to go to great lengths to get a 2nd opinion on my slide re-readings.  For me the entire procedure of re-reading took >2 months.   But I had them re-read 1.5 years after the initial diagnosis. At a major university, the re-reading of 3 biopsies cost  $550 per biopsy without insurance, and $350/biopsy with insurance (July 2007). I have seen other people post much lower prices, so it may be very different at different places.

Beth1128

Good news to me is that both path reports did agree on no invasion on the first lumpectomy so hoping that remains the same ..thanks so much for your response and I think I will have a 2nd opinion just because of all the confusion w/the first reports ..thanks again

Beth1128

Karen thanks so much for the well wishes I will def email you after I find out thanks!!!!  Beth

Anonymous

I think whenever there is a questionable result a 2nd opinion is a good idea. I was very lucky--my surgeon was going to a conference and conferred with some of his colleagues about my case, so I kinda got 2nd (and 3rd and probably 4th!) opinions free without even having to ask. My LCIS that was found on stereotactic biopsy was confirmed during lumpectomy (wide excisional biopsy), fortunately nothing more serious was found. Praying your results stay at ADH.

Anne

Sherrie1964

Leaf,

I found this thread discussion very interesting b/c I had ADH, LCIS, DCIS, and 1 cm (at greatest measure) of IDC in the left breast.  The IDC was found by ultrasound ( never showed on a mammo due to very dense breast tissue) I also have fibrocystic breast disease which complicates BSE.  I wondered how so many find LCIS, ADH, DCIS that don't present as lumps b/c mine never did until it became invasive.  Is it b/c it is more easily found on women who don't have dense breast tissue or is it found by other diagnostic tools?

I had a lumpectomy with clean margins, clean nodes, but am currently going through chemo due to age and grade of my tumor.  I'm worried about what types of future screening I should be having.

 You seem to have so much knowledge in this area, so I hope you don't mind my popping in on this discussion.  Any advice would be greatly appreciated. 

 Best,

Sherrie

Oh - I also had microcalcifications and papillomatosis (sp?) in the area that was removed. A real smorgasbord of yuk!! 

Dx 5/16/2008, IDC, 1cm, Stage Ib, Grade 3, 0/4 nodes, ER+/PR+, HER2-

leaf

Gee, you sure did have a smorgaasboard of diagnoses, Sherrie! Of course I don't mind!

Ordinarily, LCIS is diagnosed as an incidental finding at a breast biopsy. (There have been a few women here who went in for breast thickening.  But usually it is thought that LCIS doesn't show up on mammography, ultrasound, or clinical exam.) Obviously they don't do breast biopsies for nothing, but often LCIS is not found *at* the 'area of concern', but nearby.  That's one reason why its such a mysterious condition.  Even if you have 1 tiny spot of LCIS in one breast, BOTH breasts are at risk.  The physician on Up To Date (a subscription service for health professionals that reviews several hundred journals) opined that extensive areas of LCIS with nothing worse pose no more risk than if you have one tiny spot.  They often find LCIS is bilateral and multifocal.  

So they don't know how many women with LCIS (as far as I know it has not been found in men) are walking around with LCIS and don't know it. They don't know if women first have LCIS and then if that develops into invasive.  So they don't understand the natural history of the disease. The *majority* of women with LCIS (and nothing worse, maybe a bad family history is a wild card here-I have not seen any studies about LCIS + bad family history or BRCA) will not get invasive breast cancer or DCIS.

First, LCIS was thought to be analogous to DCIS. That's why they routinely gave prophylactic bilateral mastectomies to most women with LCIS and nothing worse up until about ? the mid 1990s.  This was before they discovered that lumpectomy + rads can be an option for early invasive breast cancer.  When they found lumpectomy+rads can be an option, most breast surgeons thought that its silly to do PBMs for LCIS when the majority of LCIS women will not get breast cancer at all. 

Traditionally, LCIS was thought to be a marker of higher risk for breast cancer (for unknown reasons.)

More recently, most researchers have opined that in a *small* (and no one is willing to define small) number of cases, LCIS *may* be a *nonobligate* precursor for cancer. This means that for a small number of LCIS women, LCIS *may* develop into  breast cancer.  This is on the basis of statistics and chromosome studies.  In women who present with LCIS and invasive breast cancer, often the LCIS tissue shares many gene mutations with the invasive tissue.

Almost everything about LCIS is controversial, including the name, how it should be classified, the best treatment, how women with LCIS and something worse should be handled.

There have been some studies that have indicated women with invasive + LCIS can have breast conservation if they so choose. (One paper was sponsored by the ACS.)  But this is not a universal opinion. There are other papers that opine the opposite - that women with invasive + LCIS should be treated more aggressively than women who had the same invasive without LCIS.

Best wishes on your course.  We stand here with you hand-in-hand. 

Beth1128

Anne..thanks so much for the well wishes   Beth

Sherrie1964

Leaf,

Thanks so much for your reply.  LCIS appears to be very controversial.  Mine was found as an incidental to the invasive portion and my surgeon or my oncologist did not seem concerned about it.  I was very happy though that my surgeon managed to remove the whole smorgasbord with >1cm clean margins!

Thanks again,

Sherrie