ADH on core biopsy of pleomorphic calcifications: surveillance or theatre?
A 54-year-old woman attends her first screening mammogram. The images show a 12 mm group of fine pleomorphic calcifications in the upper outer quadrant of the right breast, with no associated mass or architectural distortion. Ultrasound shows no corresponding abnormality. A stereotactic 9-gauge vacuum-assisted biopsy is performed with 12 cores; specimen radiography confirms that calcifications are present in the cores. Histology reports columnar cell change with atypical ductal hyperplasia, with no evidence of carcinoma. The case is discussed at the multidisciplinary meeting, and the surgeon asks whether further surgery is needed or whether the patient can simply return to routine screening.
1. Is this a concordant result? Justify your answer.
Read the worked answer
No - this is a discordant/high-risk result and it needs excision.
Reasoning:
- The imaging is highly suspicious. Fine pleomorphic calcifications with no mass are BI-RADS 4C/5 and are typically associated with DCIS. That is the prior probability I am matching the histology against.
- ADH is a high-risk lesion and a known under-estimator. At surgical excision, ADH found at core biopsy of suspicious calcifications is upgraded to DCIS or invasive cancer in roughly 10–30% of cases. It is also a lesion that is difficult to distinguish from low-grade DCIS on a limited sample - the difference can be one duct.
- The calcifications may not be the lesion that was sampled. Even with calcification in the cores on specimen radiography, the sampled focus may not be the most suspicious focus.
- Columnar cell change with atypia is itself part of the flat epithelial atypia spectrum and is frequently associated with adjacent DCIS.
Conclusion: the histology does not explain the mammographic finding. Recommend surgical excision with specimen radiography (or a formal vacuum-assisted excision with margin assessment where that pathway exists), and not a return to routine screening.
2. How would your answer change if histology had shown only fibrocystic change and apocrine metaplasia, and if specimen radiography had shown faint calcification in only one core while the mammographic group appeared not to have been traversed?
Read the worked answer
It would still be an excision - but for a different reason: inadequate sampling, not a high-risk lesion.
- The principle is the same: histology must explain the imaging. A benign result that does not convincingly account for a 12 mm group of pleomorphic calcifications is discordant, and discordance is an indication for further tissue, not reassurance.
- The specimen radiograph is the objective evidence. If the target was not retrieved, I cannot claim a benign diagnosis at all - the biopsy was, in effect, a sample of adjacent normal tissue. Options are a repeat stereotactic biopsy targeted at the residual calcifications, or wire-localised excision.
- This is the commonest way a breast biopsy goes wrong, and the defence is a documented specimen radiograph reviewed against the pre-biopsy images in every calcification case.
- What would make me comfortable with a benign result: the calcifications confirmed within the cores, the histology providing a recognised benign cause for calcification (fibrocystic change, sclerosing adenosis, fat necrosis), and radiological agreement at the MDT.
3. Assume she proceeds to excision and histology shows ADH only, with clear margins and no carcinoma. What surveillance do you recommend?
Read the worked answer
Annual mammographic screening, with a discussion about risk, and no routine MRI.
Reasoning:
- ADH confers an increased relative risk of subsequent breast cancer (of the order of 1.5–2 times, rising with family history and breast density), but the absolute risk over 10 years is modest and does not by itself meet the threshold for MRI in most risk models.
- Annual (rather than biennial) mammography is standard after a high-risk lesion, and may be supplemented with tomosynthesis given her dense tissue if that is available.
- Post-operative mammogram: if the specimen radiograph at excision already confirmed complete removal of the calcification group, a further post-excision mammogram is not mandatory; if there is doubt, image at 6 months to confirm clearance before returning to the screening interval.
- Refer for a formal risk assessment; if her calculated lifetime risk exceeds the local threshold (commonly 20–25%), or if there is a significant family history, discuss chemoprevention and consider surveillance MRI.
- She should be told that this is a risk factor, not a cancer, and that she should report new lumps or nipple change between screens.