Flat epithelial atypia: are we being too aggressive?

  • Ashley DiPasqualeEmail author
  • Sveta Silverman
  • Erene Farag
  • Lashan Peiris



The malignant upgrade rate of flat epithelial atypia (FEA) diagnosed on core needle biopsy varies between 0 and 30%. Excision versus observation with radiological follow-up for these lesions remains controversial. We hypothesize that the local rate of FEA is low and that close radiological surveillance is a reasonable treatment option for patients diagnosed with pure FEA on breast needle core needle biopsy.


This study was a retrospective review of a prospectively collated provincial pathology database. Patients diagnosed with FEA alone on needle core biopsy between 2006 and 2016 were included in our analysis. Patients who had FEA present together with either in situ or invasive carcinoma within the same biopsy cores were excluded. Along with patient demographics, the size of the lesion on preoperative imaging, the method of extraction, and the presence of co-existing benign and malignant pathology on final excision biopsy were analyzed. An independent pathological review was performed to confirm our results and help reduce inter-observer bias.


The local rate of malignant upgrade when pure FEA is diagnosed on a breast needle core biopsy is 12%. Age at time of diagnosis, size of original lesion on mammogram, presence of atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia on core needle biopsy, the use of vacuum-assisted biopsy (VAB), or concordant imaging did not significantly correlate with malignant upgrade risk. None of the patients who were managed with radiological follow-up had malignant upgrade during follow-up. Patients undergoing radiological follow-up alone were more likely to have a VAB, concordant imaging, and no concurrent ADH.


Our local malignant upgrade rate is consistent with published literature. We suggest radiological follow-up is a safe alternative in patients with pure flat epithelial atypia and concordant imaging, particularly those patients with small lesions in which microcalcifications can be removed completely with vacuum-assisted biopsy.


Breast neoplasm Flat epithelial atypia Treatment 


Author contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by AD, SS, EF, and LP. The first draft of the manuscript was written by AD, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.


This study was not sponsored.

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Our research satisfied all the conditions in TCPS Article 5.5 and Article 12.3. Therefore, a waiver of consent was granted for secondary use of identifiable information or identifiable human biological materials in research.


  1. 1.
    Chi-Shern HB, Hoon TP (2005) Flat epithelial atypia: concepts and controversies of an intraductal lesion of the breast. Pathology 37(2):105–111. CrossRefGoogle Scholar
  2. 2.
    Hanby A, Walker C, Tavassoli FA, Devilee P (2004) Pathology and genetics: tumours of the breast and female genital organs. WHO classification of tumours series, vol 4. IARC Press, Lyon. CrossRefGoogle Scholar
  3. 3.
    Simpson P, Gale T, Reis-Filho J et al (2005) Columnar cell lesions of the breast: the missing link in breast cancer progression? Am J Surg Pathol 29(6):734–746. CrossRefPubMedGoogle Scholar
  4. 4.
    Reis-Filho J, Simpson P, Gale T, Lakhani S (2005) The molecular genetics of breast cancer: the contribution of comparative genomic hybridization. Pathol Res Pract 201(11):713–725. CrossRefPubMedGoogle Scholar
  5. 5.
    Goldstein N, O’Malley B (1997) Cancerization of small ectatic ducts of the breast by ductal carcinoma in situ cells with apocrine snouts: a lesion associated with tubular carcinoma. Am J Clin Pathol 107(5):561–566. CrossRefPubMedGoogle Scholar
  6. 6.
    Oyama T, Maluf H, Koerner F (1999) Atypical cystic lobules: an early stage in the formation of low-grade ductal carcinoma in situ. Virchows Arch 435(4):413–421. CrossRefPubMedGoogle Scholar
  7. 7.
    Eusebi V, Feudale E, Foschini MP, Micheli A, Conti A, Riva C, DiPalma S, Rilke F (1994) Long-term follow-up of in situ carcinoma of the breast. Semin Diagn Pathol 11(3):223–235PubMedGoogle Scholar
  8. 8.
    Wisell J (2010) flat epithelial atypia on core needle biopsy: which is the right management? Yearb Pathol Lab Med 2010:26–27. CrossRefGoogle Scholar
  9. 9.
    Martel M, Barron-Rodriguez P, Tolgay-Ocal I, Dotto J, Tavassoli F (2007) Flat DIN 1 (flat epithelial atypia) on core needle biopsy: 63 cases identified retrospectively among 1,751 core biopsies performed over an 8-year period (1992–1999). Virchows Arch 451(5):883–891. CrossRefPubMedGoogle Scholar
  10. 10.
    Becker A, Gordon P, Harrison D et al (2013) Flat ductal intraepithelial neoplasia 1A diagnosed at stereotactic core needle biopsy: is excisional biopsy indicated? Am J Roentgenol 200(3):682–688. CrossRefGoogle Scholar
  11. 11.
    Senetta R, Campanino P, Mariscotti G et al (2009) Columnar cell lesions associated with breast calcifications on vacuum-assisted core biopsies: clinical, radiographic and histological correlations. Mod Pathol 22(6):762–769. CrossRefPubMedGoogle Scholar
  12. 12.
    World Medical Association (WMA) (2009) Declaration of Helsinki. Ethical principles for medical research involving human subjects. Jahrb Wiss Ethik. CrossRefGoogle Scholar
  13. 13.
    Chan P, Chotai N, Lai E et al (2018) Majority of flat epithelial atypia diagnosed on biopsy do not require surgical excision. Breast 37:13–17. CrossRefPubMedGoogle Scholar
  14. 14.
    Lavoué V, Roger C, Poilblanc M et al (2010) Pure flat epithelial atypia (DIN 1a) on core needle biopsy: study of 60 biopsies with follow-up surgical excision. Breast Cancer Res Treat 125(1):121–126. CrossRefPubMedGoogle Scholar
  15. 15.
    Bianchi S, Bendinelli B, Castellano I et al (2012) Morphological parameters of flat epithelial atypia (FEA) in stereotactic vacuum-assisted needle core biopsies do not predict the presence of malignancy on subsequent surgical excision. Virchows Arch 461(4):405–417. CrossRefPubMedGoogle Scholar
  16. 16.
    Ingegnoli A, Aloia C, Frattaruolo A et al (2010) Flat epithelial atypia and atypical ductal hyperplasia: carcinoma underestimation rate. Breast J 16(1):55–59. CrossRefPubMedGoogle Scholar
  17. 17.
    Peres A, Barranger E, Becette V, Boudinet A, Guinebretiere J, Cherel P (2011) Rates of upgrade to malignancy for 271 cases of flat epithelial atypia (FEA) diagnosed by breast core biopsy. Breast Cancer Res Treat 133(2):659–666. CrossRefPubMedGoogle Scholar
  18. 18.
    Canadian Cancer Society’s Advisory Committee on Cancer Statistics (2016) Canadian Cancer Statistics 2016. Canadian Cancer Society, TorontoGoogle Scholar
  19. 19.
    David N, Labbe-Devilliers C, Moreau D, Loussouarn D, Campion L (2007) Diagnosis of flat epithelial atypia after stereotactic vacuum-assisted biopsy of the breast: what is the best management: systematic surgery for all or follow-up? Clin Imaging 31(3):221. CrossRefGoogle Scholar
  20. 20.
    Boulos F, Dupont W, Schuyler P et al (2011) Clinicopathologic characteristics of carcinomas that develop after a biopsy containing columnar cell lesions. Cancer 118(9):2372–2377. CrossRefPubMedGoogle Scholar
  21. 21.
    Schiaffino S, Gristina L, Villa A, Tosto S, Monetti F, Carli F, Calabrese M (2018) Flat epithelial atypia: conservative management of patients without residual microcalcifications post-vacuum-assisted breast biopsy. Br J Radiol 91(1081):20170484. CrossRefPubMedGoogle Scholar
  22. 22.
    Calhoun BC, Sobel A, White RL, Gromet M, Flippo T, Sarantou T, Livasy CA (2015) Management of flat epithelial atypia on breast core biopsy may be individualized based on correlation with imaging studies. Mod Pathol 28(5):670–676. CrossRefPubMedGoogle Scholar
  23. 23.
    Hartmann L, Radisky D, Frost M et al (2014) Understanding the premalignant potential of atypical hyperplasia through its natural history: a longitudinal cohort study. Cancer Prev Res 7(2):211–217. CrossRefGoogle Scholar
  24. 24.
    Page D, Schuyler P, Dupont W, Jensen R, Plummer W, Simpson J (2003) Atypical lobular hyperplasia as a unilateral predictor of breast cancer risk: a retrospective cohort study. Lancet. 361(9352):125–129. CrossRefPubMedGoogle Scholar
  25. 25.
    Ferrini R, Mannino E, Ramsdell E, Hill L (1996) Screening mammography for breast cancer: American College of preventive medicine practice policy statement. Am J Prev Med 12(5):340–341CrossRefGoogle Scholar
  26. 26.
    Hugar SB, Bhargava R, Dabbs DJ, Davis KM, Zuley M, Clark BZ (2019) Isolated flat epithelial atypia on core biopsy specimens is associated with a low risk of upgrade at excision. Am J Clin Pathol 151(5):511–515. CrossRefPubMedGoogle Scholar
  27. 27.
    McCroskey Z, Sneige N, Herman CR, Miller RA, Venta LA, Ro JY, Schwartz MR, Ayala AG (2018) Flat epithelial atypia in directional vacuum-assisted biopsy of breast microcalcifications: surgical excision may not be necessary. Mod Pathol 31:1097–1106CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of AlbertaEdmontonCanada
  2. 2.Department of Laboratory Medicine, Covenant Health, Misericordia Community HospitalUniversity of AlbertaEdmontonCanada
  3. 3.Department of Surgery, Covenant Health, Misericordia Community HospitalUniversity of AlbertaEdmontonCanada

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