Safety of de-escalation of surgical intervention for atypical ductal hyperplasia on percutaneous biopsy: One size does not fit all

Published:September 23, 2022DOI:


      • LOW comprises 21% of our ADH population.
      • LOW effectively identifies ADH at lowest risk for upgrade (0%).
      • 0% of LOW in AM developed a breast cancer at ADH site in follow up.



      Oncologic safety of active monitoring (AM) for atypical ductal hyperplasia (ADH) on core-needle biopsy (CNB) is not well defined. We sought to define oncologic outcomes for AM to manage ADH meeting institutional predefined low-risk criteria (LOW).


      ADH was diagnosed on CNB from 10/2015-03/2020. LOW (pure ADH, size <1 cm, >50% removed by CNB, <3 foci, and no necrosis) patients were offered AM; all others were recommended for surgical excision. Oncologic outcomes were compared for AM and surgery.


      111 were included, 21 (19%) meeting LOW. AM occurred in 18 (86%) while 3 elected for excision (with 0% upgrade). Of the 18 LOW in AM, 2 required additional CNB (none at ADH site): 0% were diagnosed with cancer over median 23 month follow-up.


      There were no missed cancers at ADH site during AM for LOW, confirming the oncologic safety of AM in this select group.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cancer Facts & Figures
        American cancer society.
        • Hartmann L.C.
        • Degnim A.C.
        • Santen R.J.
        • Dupont W.D.
        • Ghosh K.
        Atypical hyperplasia of the breast — risk assessment and management options.
        N Engl J Med. 2015; 372
        • Gutwein L.G.
        • Ang D.N.
        • Liu H.
        • et al.
        Utilization of minimally invasive breast biopsy for the evaluation of suspicious breast lesions.
        Am J Surg. 2011; 202: 127-132
        • American Society of Breast Surgeons
        Consensus Guideline on Concordance Assessment of Image-Guided Breast Biopsies and Management of Borderline or High-Risk Lesions. 2020
        • Page D.L.
        • Dupont W.D.
        • Rogers L.W.
        • Rados M.S.
        Atypical hyperplastic lesions of the female breast. A long-term follow-up study.
        Cancer. 1985; 55 (<2698::AID-CNCR2820551127>3.0.CO;2-A): 2698-2708
      1. National Comprehensive Cancer Network Clinical Guidelines. Breast Cancer Screening and Diagnosis, 2020 (vol. 1)
        • Racz J.M.
        • Degnim A.C.
        When does atypical ductal hyperplasia require surgical excision?.
        Surg Oncol Clin. 2018; 27: 23-32
        • Ely K.A.
        • Carter B.A.
        • Jensen R.A.
        • Simpson J.F.
        • Page D.L.
        Core biopsy of the breast with atypical ductal hyperplasia.
        Am J Surg Pathol. 2001; 25: 1017-1021
        • Mooney K.L.
        • Bassett L.W.
        • Apple S.K.
        Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: a single-institution experience and literature review.
        Mod Pathol. 2016; 29: 1471-1484
        • Peña A.
        • Shah S.S.
        • Fazzio R.T.
        • et al.
        Multivariate model to identify women at low risk of cancer upgrade after a core needle biopsy diagnosis of atypical ductal hyperplasia.
        Breast Cancer Res Treat. 2017; 164: 295-304
        • Lamb L.R.
        • Bahl M.
        • Hughes K.S.
        • Lehman C.D.
        Pathologic upgrade rates of high-risk breast lesions on digital two-dimensional vs tomosynthesis mammography.
        J Am Coll Surg. 2018; 226: 858-867
        • Linsk A.
        • Mehta T.S.
        • Dialani V.
        • et al.
        Surgical upgrade rate of breast atypia to malignancy: an academic center's experience and validation of a predictive model.
        Breast J. 2018; 24: 115-119
        • Sutton T.
        • Farinola M.
        • Johnson N.
        • Garreau J.R.
        Atypical ductal hyperplasia: clinicopathologic factors are not predictive of upgrade after excisional biopsy.
        Am J Surg. 2019; 217: 848-850
        • Weiss J.B.
        • Do W.S.
        • Forte D.M.
        • Sheldon R.R.
        • Childers C.K.
        • Sohn V.Y.
        Is bigger better? Twenty-year institutional experience of atypical ductal hyperplasia discovered by core needle biopsy.
        Am J Surg. 2019; 217: 906-909
        • Sergesketter A.R.
        • Thomas S.M.
        • Fayanju O.M.
        • et al.
        The influence of age on the histopathology and prognosis of atypical breast lesions.
        J Surg Res. 2019; 241: 188-198
        • Williams K.E.
        • Amin A.L.
        • Hill J.
        • et al.
        Radiologic and pathologic features associated with upgrade of atypical ductal hyperplasia at surgical excision.
        Acad Radiol. 2019; 26: 893-899
        • Wagoner M.J.
        • Laronga C.
        • Acs G.
        Extent and histologic pattern of atypical ductal hyperplasia present on core needle biopsy specimens of the breast can predict ductal carcinoma in situ in subsequent excision.
        Am J Clin Pathol. 2009; 131: 112-121
        • Krishnamurthy S.
        • Bevers T.
        • Kuerer H.
        • Yang W.T.
        Multidisciplinary considerations in the management of high-risk breast lesions.
        Am J Roentgenol. 2012; 198: W132-W140
        • Forgeard C.
        • Benchaib M.
        • Guerin N.
        • et al.
        Is surgical biopsy mandatory in case of atypical ductal hyperplasia on 11-gauge core needle biopsy? a retrospective study of 300 patients.
        Am J Surg. 2008; 196: 339-345
        • Kohr J.R.
        • Eby P.R.
        • Allison K.H.
        • et al.
        Risk of upgrade of atypical ductal hyperplasia after stereotactic breast biopsy: effects of number of foci and complete removal of calcifications.
        Radiology. 2010; 255: 723-730
        • Nguyen C.V.
        • Albarracin C.T.
        • Whitman G.J.
        • Lopez A.
        • Sneige N.
        Atypical ductal hyperplasia in directional vacuum-assisted biopsy of breast microcalcifications: considerations for surgical excision.
        Ann Surg Oncol. 2011; 18: 752-761
        • McGhan L.J.
        • Pockaj B.A.
        • Wasif N.
        • Giurescu M.E.
        • McCullough A.E.
        • Gray R.J.
        Atypical ductal hyperplasia on core biopsy: an automatic trigger for excisional biopsy?.
        Ann Surg Oncol. 2012; 19: 3264-3269
        • McLaughlin C.T.
        • Neal C.H.
        • Helvie M.A.
        Is the upgrade rate of atypical ductal hyperplasia diagnosed by core needle biopsy of calcifications different for digital and film-screen mammography?.
        Am J Roentgenol. 2014; 203: 917-922
        • Khoury T.
        • Chen X.
        • Wang D.
        • et al.
        Nomogram to predict the likelihood of upgrade of atypical ductal hyperplasia diagnosed on a core needle biopsy in mammographically detected lesions.
        Histopathology. 2015; 67: 106-120
        • Kilgore L.J.
        • Yi M.
        • Bevers T.
        • et al.
        Risk of breast cancer in selected women with atypical ductal hyperplasia who do not undergo surgical excision.
        Ann Surg. March 2021;
        • Schiaffino S.
        • Calabrese M.
        • Melani E.F.
        • et al.
        Upgrade rate of percutaneously diagnosed pure atypical ductal hyperplasia: systematic review and meta-analysis of 6458 lesions.
        Radiology. 2020; 294: 76-86
        • Menen R.S.
        • Ganesan N.
        • Bevers T.
        • et al.
        Long-term safety of observation in selected women following core biopsy diagnosis of atypical ductal hyperplasia.
        Ann Surg Oncol. 2017; 24: 70-76