Management of Benign Breast Biopsy with Proliferative Lesions Without Atypia
This patient requires no additional intervention beyond routine age-appropriate annual screening mammography starting at age 40, with no short-interval follow-up imaging needed. 1
Classification and Risk Stratification
The pathology findings described represent proliferative lesions without atypia, which include: 2
- Usual ductal hyperplasia - proliferative without atypia
- Sclerosing adenosis - proliferative without atypia
- Columnar cell change - nonproliferative to minimally proliferative
- Apocrine metaplasia - nonproliferative (fibrocystic change)
- Stromal fibrosis - nonproliferative
These lesions carry only a modest increase in breast cancer risk (1.5-1.9x baseline), substantially lower than atypical hyperplasia (4.5-5.3x baseline). 1 While almost 30% of women with breast cancer have a history of benign breast disease, this represents a relevant but not alarming risk factor. 2, 1
Recommended Surveillance Strategy
Imaging Protocol
Annual screening mammography starting at age 40 is the appropriate surveillance modality, with digital breast tomosynthesis (DBT) preferred over standard mammography. 1 The ACR and Society of Breast Imaging recommend this approach because: 2, 1
- DBT increases cancer detection rates compared to standard mammography
- DBT decreases false-positive recall rates
- No short-interval (6-month) follow-up imaging is indicated - studies demonstrate that 6-month surveillance intervals do not improve cancer detection rates, invasive cancer rates, stage, tumor size, or nodal status compared to routine annual screening 2, 1
MRI Screening
MRI screening is NOT indicated for proliferative lesions without atypia. 2 MRI may be warranted only for proliferative lesions WITH atypia (atypical ductal hyperplasia, atypical lobular hyperplasia, LCIS, flat epithelial atypia), which are not present in this case. 2
Important Clinical Considerations
Mammographic Performance
Women with a history of benign breast biopsies show no difference in mammographic sensitivity but may have decreased specificity compared to women without prior biopsies. 2, 1 This decreased specificity is attributed to tissue characteristics (such as the sclerosing adenosis and stromal fibrosis present in this case) rather than the biopsy procedure itself. 2
Family History Impact
Family history has minimal effect on risk in women with nonproliferative or proliferative lesions without atypia, unlike atypical hyperplasia where family history dramatically amplifies risk. 1 Standard screening recommendations apply regardless of family history in this scenario.
Specific Lesion Considerations
Sclerosing Adenosis
Sclerosing adenosis is associated with approximately a doubling of breast cancer risk but does not require any intervention beyond routine screening. 3 It can mimic carcinoma on imaging but once confirmed benign on biopsy, requires only standard surveillance. 3
Apocrine Metaplasia
Apocrine metaplasia in sclerosing lesions is benign and does not require immediate treatment with surgery or radiation. 4 Long-term studies show no development of breast carcinoma during follow-up periods in women with atypical apocrine sclerosing lesions. 4
Columnar Cell Change
Columnar cell change without atypia is managed with routine screening only. 5 It becomes clinically significant only when flat epithelial atypia is present, which would then be classified as a proliferative lesion with atypia requiring different management. 2, 5
Key Management Pitfalls to Avoid
- Do not order short-interval (6-month) follow-up imaging - this is unnecessary and not evidence-based for proliferative lesions without atypia 2, 1
- Do not confuse this with atypical hyperplasia - the absence of atypia is critical; atypical ductal hyperplasia would typically warrant surgical excision 2, 1
- Do not recommend MRI screening - this is not indicated for average-risk women or those with proliferative lesions without atypia 2