What is the management protocol for a patient with atypical ductal hyperplasia (ADH) and microcalcifications?

Management Protocol for Atypical Ductal Hyperplasia with Microcalcifications

Atypical ductal hyperplasia (ADH) diagnosed on core biopsy of microcalcifications requires surgical excision in most cases due to a 20-30% risk of upgrade to DCIS or invasive carcinoma, but highly selected patients with complete removal of small lesions may be candidates for surveillance alone. 1, 2

Initial Diagnostic Approach

Imaging Evaluation

• Obtain standard two-view mammography plus magnification views to accurately characterize the microcalcifications and determine their maximal span, as standard views alone underestimate disease extent by two centimeters in up to 50% of cases 3
• Perform bilateral mammography to evaluate the contralateral breast, as bilateral disease occurs in approximately 19% of cases 3
• Use stereotactic core needle biopsy (not frozen section) for nonpalpable microcalcifications, obtaining at least 3-5 cores to ensure adequate sampling 2

Critical Technical Requirements

• Perform specimen radiography to confirm retrieval of microcalcifications 2, 3
• Leave some microcalcifications at the biopsy site when possible to allow accurate localization for definitive excision if needed 2, 3
• Avoid frozen section examination for microcalcifications, as distinguishing ADH from DCIS may be impossible and small foci of microinvasion can be lost or rendered uninterpretable by freezing artifact 4

Surgical Excision Decision Algorithm

Mandatory Excision Criteria (High Risk of Upgrade)

Proceed with surgical excision if ANY of the following are present:

• Age >50 years 5
• Lesion diameter ≥21 mm on mammography 6
• Mass lesion present on mammography 5

• 2 ADH foci on histology 6, 7, 8

• Significant cytologic atypia suspicious for intermediate or high-grade carcinoma 7
• Presence of necrosis 7
• ≤95% removal of targeted calcifications 7
• Shorter length of biopsy core 5
• Family or personal history of breast cancer 8

Potential Surveillance Candidates (Lower Risk)

Consider surveillance without excision ONLY if ALL of the following criteria are met:

• Age ≤50 years 5
• Lesion <6 mm with complete removal of microcalcifications 6
• ≤2 ADH foci 6, 7
• No significant cytologic atypia or necrosis 7

• 95% removal of targeted calcifications 7

• No mass lesion on mammography 5
• No family history of breast cancer 8

Important caveat: Even in this highly selected low-risk group, the upgrade rate to malignancy is still 2-3%, and some institutions recommend routine excision for all ADH cases given the 18-28% overall upgrade rate 5, 6, 7

Surgical Excision Technique

Specimen Handling

• Orient the specimen (superior, medial, lateral) for the pathologist with sutures or other markers 4
• Mark margins with India ink to determine presence or absence of tumor at margins of excision 4
• Submit the entire mammographic lesion and as much of the remaining specimen as practical for histologic examination 4
• Ensure specimen radiograph is available to the pathologist for review while examining the specimen 4

Re-excision for Positive Margins

• Re-excise carefully if margins are inadequate, using needle localization if microcalcifications are the indication for re-excision 4
• Remove a rim of tissue around the previous biopsy site when the site of inadequate margins is not known 4

Axillary Management

• Axillary dissection is NOT necessary for ADH, as axillary node metastases are uncommon 4

Risk Reduction and Long-Term Management

Chemoprevention

Strongly consider tamoxifen 20 mg daily for 5 years, which provides a 75% reduction in invasive breast cancer occurrence in women with ADH (Category 1 evidence) 1

Surveillance Protocol

All women with ADH require lifelong surveillance regardless of whether they undergo surgery or take tamoxifen:

• History and physical examination every 6-12 months for 5 years, then annually 1
• Annual diagnostic mammography 1
• Monitor for thromboembolic symptoms and perform baseline and periodic gynecologic evaluation if on tamoxifen 1

Risk Counseling

• ADH confers a 4- to 5-fold increased risk of developing invasive breast cancer 1
• Continuous annual breast cancer risk is approximately 0.5% to 1.0%, with cumulative 10-year risk 2.6 times higher than women without ADH 1
• Risk doubles with associated family history of breast cancer 1
• Risk remains elevated in both breasts for decades, with continued risk documented at 17 years median follow-up 1

Common Pitfalls to Avoid

• Never rely on ultrasound alone for evaluation of calcifications, as ultrasound usually cannot visualize microcalcifications adequately 2
• Never assume a benign core biopsy result is definitive without confirming radiologic-pathologic concordance 2
• Never proceed with observation alone for ADH without careful consideration of all risk factors, as excision remains the standard of care in most cases 2
• Never use frozen section for microcalcifications, as this compromises the ability to distinguish ADH from DCIS 4