Columnar Cell Lesions of the Breast: CCC, CCH and Flat Epithelial Atypia, Approach and MCQs

Subtitle: Columnar cell lesions of the breast: columnar cell change, columnar cell hyperplasia and flat epithelial atypia, how to separate them, when to call ADH or low-grade DCIS, IHC, risk, management and 8 MCQs.

Author: PathologyMCQ Editorial Board

Category: Breast Pathology

Last Updated: October 2026

Read Time: 6 minutes

At-a-Glance

CCC: 1–2 layers of bland columnar cells, apical snouts, secretions.
CCH: >2 layers (stratified, tufted), still no atypia.
FEA: low-grade monomorphic cytological atypia, no complex architecture.
Add rigid bars, bridges or micropapillae and it becomes ADH or low-grade DCIS.
Often found because of microcalcifications; part of the low-grade neoplasia family.

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The Three Lesions

Columnar cell lesions (WHO)

Lesion	Layers	Atypia	Architecture
Columnar cell change (CCC)	1–2	None	Flat; apical snouts, secretions
Columnar cell hyperplasia (CCH)	>2 (stratified)	None	Tufts, mounds; no bridges
Flat epithelial atypia (FEA)	1 to several	Low-grade monomorphic	Flat; no bars, bridges or micropapillae
ADH / low-grade DCIS	Variable	Low-grade monomorphic	Rigid bars, cribriform, micropapillae

Step-by-Step Approach

1. Identify columnar cells lining dilated TDLU acini, often with apical snouts and calcified secretions.
2. Count layers: 1–2 = change; >2 = hyperplasia.
3. Look at the nuclei at low and high power: rounded, evenly spaced, monotonous nuclei with loss of polarity = FEA. Elongated, polarised nuclei = no atypia.
4. Look for architecture: rigid bars, Roman bridges, cribriform spaces or micropapillae mean ADH (small focus) or low-grade DCIS.
5. Search the rest of the biopsy for lobular neoplasia and tubular carcinoma, which often coexist.
6. Correlate with imaging (calcifications sampled?) and discuss at the MDT.

IHC and Risk

FEA, ADH and low-grade DCIS: strong diffuse ER, CK5/6 negative.
CCC/CCH and usual hyperplasia: heterogeneous ER, mosaic CK5/6.
Risk: CCC/CCH confer little extra risk; isolated FEA has a low progression risk. FEA on a core biopsy is often excised or followed according to radiology concordance and local policy, especially when calcifications remain.

Case Question

Columnar cell lesion case image — Which columnar cell lesion is this? Stratified columnar cells (more than two layers) without atypia or complex architecture = columnar cell hyperplasia.

Test Yourself: 8 MCQs

Columnar cell lesions: 8 MCQs

CCC, CCH, FEA and the low-grade family, with instant explanations.

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Exam Pearls

Layers separate CCC from CCH; atypia separates FEA.
FEA + architecture = ADH or low-grade DCIS.
Rosen triad: CCL, lobular neoplasia, tubular carcinoma.
FEA: ER strong, CK5/6 negative.

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References

WHO Classification of Tumours Editorial Board. Breast Tumours. 5th ed. IARC; 2019.
Schnitt SJ, Vincent-Salomon A. Columnar cell lesions of the breast. Adv Anat Pathol. 2003;10:113–24.