Fibrocystic changes

Columnar cell change / hyperplasia

Topic Completed: 1 May 2010

Minor changes: 12 August 2021

Copyright: 2002-2021,, Inc.

PubMed Search: Columnar cell lesions of breast [title]

Hind Warzecha, M.D.
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Cite this page: Warzecha H. Columnar cell change / hyperplasia. website. Accessed October 25th, 2021.
Definition / general
  • Unknown
  • Classification below is by Schnitt (Adv Anat Pathol 2003;10:113), modified by Simpson (Am J Surg Pathol 2005;29:734)
  • Note: all have variable dilated acini, cytoplasmic snouts and intraluminal secretions
  • Several types may coexist in same breast
  • Note: classifications with atypia (types 3 - 6) have lowest diagnostic reproducibility (J Clin Pathol 2005;58:705)
  • Type 1 (columnar cell change, CCC): 1 - 2 cell layers
  • Columnar cells have uniform ovoid / elongated nuclei perpendicular to basement membrane; no / inconspicuous nucleoli; may have apical snouts but usually not prominent
  • Type 2 (columnar cell hyperplasia, CCH): > 2 stratified cell layers with variable nuclear crowding and cellular micropapillations but no complex architectural patterns (i.e. no rigid bars, bridges or well formed micropapillary structures); cytology similar to type 1 but may have hobnail cells
  • Associated with intraluminal calcification
  • Type 3 (columnar cell hyperplasia with architectural atypia): > 2 stratified cell layers with complex architectural patterns (micropapillary, tufts, fronds, arcades, rigid bridges or punched out spaces); type 2 cytology
  • Type 4 (columnar cell hyperplasia with cytologic atypia): type 2 architecture; mild to moderate cytologic atypia, may resemble tubular carcinoma
  • Type 5 (columnar cell hyperplasia with cytologic and architectural atypia): type 3 architecture; type 4 cytology
  • Type 6 (columnar cell change with cytologic atypia): 1 - 2 cell layers; type 4 cytology
  • Note: can also be classified as (a) no nuclear atypia and less pronounced hyperplasia; or (b) generally more atypical (Pathology 2010;42:28)
  • WHO recognizes flat epithelial atypia (FEA) as a category defined by the presence of "a neoplastic intraductal proliferation characterized by replacement of the native epithelial cells by a single or 3 - 5 layers of mildly atypical cells" (synonyms: Simpson type 4 and type 6 and Schnitt CCC and CCH with cytologic atypia, IARC: Pathology and Genetics of Tumours of the Breast and Female Genital Organs, First Edition, 2003 [pages 65 - 66])
Clinical features
  • Nonspecific, similar to fibrocystic change in general, usually a mammographic finding
Radiology description
  • Calcifications can be round, with indistinct shape or pleomorphic (Pathology 2009;41:18)
  • In most cases, indeterminate or suspicious microcalcifications or BI-RADS category 4
  • Ossifying type calcifications: a peculiar, infrequent type of calcification found in mammary duct lumina, with a central core of calcification and a rim of ossifying type matrix reminiscent of osseous tissue but not lined by osteoblasts or osteocytes (Arch Pathol Lab Med 2002;126:995)
Prognostic factors
  • May be associated with atypical hyperplasia but otherwise no significantly increased risk of breast carcinoma (Cancer 2008;113:2415)
Case reports
  • Excision is recommended if atypia is found at core biopsy (Am Surg 2007;73:984); excision is not done in cases without atypia
  • Recommended to merely identify ADH, DCIS or invasion on excision; in these cases the treatment is similar to that of ADH, DCIS or invasive carcinoma
  • If flat epithelial atypia (FEA) is the "highest grade" lesion found on excision, submit additional tissue / obtain additional levels to rule out ADH / DCIS (Am J Surg Pathol 2002;26:1095); if ADH / DCIS is not present, no further treatment is required (Mod Pathol 2009;22:762)
Gross description
  • No specific gross features
Microscopic (histologic) description
  • Enlarged terminal duct lobular units (TDLUs) lined by tightly packed columnar epithelial cells with prominent apical cytoplasmic snouts and intraluminal secretions
  • Cells may have clear or granular cytoplasm
  • Variable cytologic atypia and architectural complexity (see classification)
  • May have pseudoangiomatous hyperplasia-like stroma (Int J Clin Exp Pathol 2009;3:87)
  • By hierarchical cluster analysis, features are very heterogeneous (Pathology 2010;42:28)
Microscopic (histologic) images

Images hosted on other servers:

Columnar cell change - various images

PASH-like stroma (H&E)



Various images: contributed
by Dr. Semir Vranić, Clinical Center
of the University of Sarajevo
(Bosnia and Herzegovina)

Columnar cell hyperplasia - various images

Various images

Cytology description
  • Flat sheets of cells with distinct cell borders, finely granular cytoplasm and enlarged nuclei
  • Usually few myoepithelial cells
  • Resembles papillary neoplasms and well differentiated adenocarcinoma (Diagn Cytopathol 2007;35:73)
  • Atypical features: cohesive 3D clusters of enlarged polygonal epithelial cells mixed with myoepithelial cells centrally and palisading columnar cells peripherally; often bipolar nuclei and apical snouts (Diagn Cytopathol 2004;31:370)
Positive stains
Negative stains
Electron microscopy description
  • Epithelial cells and myoepithelial cells plus associated basement membrane-like material (Breast J 2000;6:199)
Molecular / cytogenetics description
Differential diagnosis
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