What is the appropriate management for a 47-year-old female with a positive family history of breast cancer, bilateral increased density and glandular pattern on mammogram, and atypical ductal hyperplasia on core needle biopsy (CNB)?

Management of Atypical Ductal Hyperplasia Diagnosed on Core Needle Biopsy

Wire surgical excision is the appropriate management for a 47-year-old female with a positive family history of breast cancer, bilateral increased density and glandular pattern on mammogram, and atypical ductal hyperplasia (ADH) on core needle biopsy. 1

Rationale for Surgical Excision

The recommendation for surgical excision of ADH found on core needle biopsy is based on the significant risk of upgrade to malignancy when the complete lesion is examined. This approach is supported by multiple guidelines and research findings:

• The NCCN Guidelines explicitly recommend excisional biopsy when core needle biopsy reveals atypical ductal hyperplasia 1
• Studies show an underestimation of cancer when atypical hyperplasia is diagnosed by core needle biopsy 1
• The ACR Appropriateness Criteria acknowledges that a majority of experts agree on the need for surgical excision when atypical ductal hyperplasia is found on core biopsy 1

Upgrade Rates and Risk Factors

The risk of upgrade to DCIS or invasive carcinoma is substantial:

• Recent studies show upgrade rates of 16.5% to malignancy (DCIS or invasive cancer) following excision of ADH diagnosed on core biopsy 2
• Older studies have shown even higher rates, with one study reporting 15.6% invasive carcinoma and 22.2% high-grade DCIS upon excision 3

This patient has additional risk factors that further support surgical excision:

• 47 years of age (middle-aged)
• Positive family history of breast cancer
• Bilateral increased density on mammogram (which can both obscure lesions and is an independent risk factor)

Surgical Approach

Wire surgical excision (option A) is the most appropriate management because:

• It allows for complete removal of the lesion with adequate margins
• It preserves breast tissue compared to simple mastectomy
• It enables definitive diagnosis by examining the entire lesion
• It provides therapeutic benefit if the lesion is upgraded to malignancy

The procedure typically involves:

• Needle or wire localization performed by a radiologist immediately before the excisional biopsy
• Removal of the entire suspicious area
• Proper orientation of the specimen for pathological examination 1

Why Not Alternative Options?

• Simple mastectomy (option B) would be overly aggressive for ADH, which is a high-risk lesion but not malignant. Mastectomy would remove excessive breast tissue unnecessarily.

• Lumpectomy (option C) is essentially the same procedure as wire-guided excisional biopsy in this context, but the term "wire surgical excision" more accurately describes the technique needed for a non-palpable lesion identified on imaging.

Post-Excision Considerations

After surgical excision:

• A postoperative mammogram should be obtained to document complete removal of the mammographic abnormality 1
• If the final pathology confirms only ADH without malignancy, the patient should be counseled about her increased risk of developing breast cancer
• For patients with confirmed ADH and additional risk factors (like family history), consideration of risk reduction strategies may be warranted, including:
  • Enhanced surveillance
  • Possible chemoprevention with agents like tamoxifen 4

Recent Developments

The most recent research (2023) suggests that very focal ADH (defined as 1 focus spanning ≤2 mm) may have a lower upgrade rate of around 7% 5. However, this patient's clinical scenario (family history, bilateral increased density) warrants the standard approach of surgical excision rather than observation.