Atypical Ductal Hyperplasia of the Breast

Atypical ductal hyperplasia (ADH) is an abnormal growth of cells in the breast. It is not breast cancer but is considered a precancerous condition. ADH is typically diagnosed with a biopsy after a suspicious area is found on an imaging test (e.g., mammogram or ultrasound) or during a physical exam. If found, atypical ductal hyperplasia will require close monitoring.

ADH is similar to atypical lobular hyperplasia (ALH). However, ALH involves epithelial cells lining the lobules of the breast rather than the ducts.

Symptoms

Atypical ductal hyperplasia usually doesn't cause any notable symptoms. It is usually a subsequent finding of a biopsy done to evaluate a benign breast lump or findings on mammogram imaging. Atypical ductal hyperplasia may cause breast pain, though this is rare.

Since ADH can go undetected until testing for a potential breast cancer diagnosis is done, it's important that you are aware of the signs and symptoms of breast cancer and see your healthcare provider if you notice any changes in your breast that concern you.

Causes

A specific cause for atypical ductal hyperplasia is unknown. Normal cells overproduce. And as that continues, they begin to become irregular. If the condition is not properly managed, it will continue to progress and eventually become breast cancer. It may also affect nearby tissues. 

The risk factors for ADH are similar to those for all types of breast cancer, including:

• Getting older: The risk for breast cancer and benign breast conditions increases with age; most breast cancers are diagnosed after age 50.
• Genetic mutations: Inherited mutation of certain genes, such as BRCA1 and BRCA2
• Reproductive health history: This includes early menstruation (before age 12) and starting menopause after age 55. Having a pregnancy after age 30, not breastfeeding, and never having a full-term pregnancy are also risk factors.
• Have dense breast tissue: Dense breasts have more connective tissue than fatty tissue, which allows cancerous cells room to grow.
• Family history: A woman’s risk is higher if she has a first-degree relative (parent, sibling, child) who has had breast cancer, or multiple family members (on both parents’ sides) who have had breast cancer.
• Previous radiation treatments: A woman who has had previous radiation therapy to her chest or breasts before age 30 has a higher risk of getting breast cancer.
• Activity level and/or weight: Not being active and/or being overweight after menopause can increase your risk.
• Taking hormones: Birth control pills and hormone replacement therapy have been shown to raise risk.
• Alcohol consumption: Overconsumption of alcohol may play a role.
• Carcinogen exposure: Exposure to substances that cause cancer, including smoking, also increases the risk for breast cancer and benign breast conditions. 

Diagnosis

Again, a breast biopsy is the only definitive test for diagnosing atypical ductal hyperplasia. A tissue sample may be obtained by either a core needle biopsy (needle localization biopsy during an ultrasound) or by an open surgical breast biopsy.

With ADH, the pattern of cell growth is abnormal and may have some features of ductal carcinoma in situ (DCIS), which is considered a pre-invasive cancer in the ducts of the breast. When a biopsy finds atypical ductal hyperplasia, more tissue will be surgically removed and tested to make sure there is nothing else more serious in breast tissue.

Your healthcare provider may recommend a breast biopsy if you present with certain signs or symptoms of breast cancer (particularly if you have risk factors for the disease), or may do so only after other, less invasive tests are done.

Though the following cannot confirm a diagnosis of atypical ductal hyperplasia, they may yield results that strengthen the possibility of one:

• Mammography: ADH often appears as a pattern of calcifications on a mammogram.
• Ultrasound: An ultrasound uses sound waves to assess the appearance of a lump or thickening in the breast and may also reveal calcifications.
• Ductal lavage: Breast cells are withdrawn through the nipple using a suction technique. Under the microscope, some of these cells may appear atypical.

What Is the Treatment for Atypical Ductal Hyperplasia?

Once you've been diagnosed with ADH, you'll be asked to make a choice about what to do next. You have several options, all of which are worth discussing in relation to your health and history with your healthcare provider.

Watching and Waiting

When you are diagnosed with ADH, your healthcare provider will likely refer you to a breast specialist for further discussion. Most cases of ADH should be surgically removed given the risk of finding early breast cancer with excision.

However, there may be select cases that are appropriate for observation, with serial imaging to follow closely to assess for changes at the site of prior biopsy.

Medication

Your healthcare provider may suggest medications that prevent breast cancer, including selective estrogen receptor modulators (SERMs) that block estrogen from acting on certain cells. 

Surgery

Surgery may be a better choice if you are at high risk of developing breast cancer—for example, you are younger than age 50 with larger tumors or tumors that can be felt on exam. That said, it is also an option if you don't have such risk factors but are very concerned about your diagnosis of atypical ductal hyperplasia.

In either case, but particularly if you are not considered high-risk, speak with your healthcare provider about the pros and cons of your surgical options:

• Ultrasound-guided, vacuum-assisted excision: This relatively non-invasive method removes the atypical tissue area. However, it may not be appropriate for everyone.
• Lumpectomy: This involves removing the tissue containing the area of abnormal cells plus a margin of surrounding tissue to help prevent recurrence.
• Mastectomy: Some women have areas of ADH that are widely scattered throughout their breast(s). When this occurs, a woman may opt to have a mastectomy to remove all potentially abnormal breast tissue.

Summary

Atypical ductal hyperplasia is an abnormal growth of cells in the milk ducts or lobes of the breast. It is considered precancerous. When a suspicious area is found on an image or during a physical exam it is diagnosed with a biopsy. ADH usually has no noticeable symptoms and the cause is unknown, but risks include factors like age, genetic makeup, and a history of hormone use. If a diagnosis of ADH is confirmed, options include a wait-and-see approach, medication, or surgery.