Background: Columnar cell lesions (CCLs) of the breast are a unique and complex category in breast pathology, characterized by alterations in cellular structure and arrangement. This systematic review aims to explores the features of CCLs, emphasizing their diagnostic complexities and potential implications for breast cancer prevention and management. Methods: The study followed PRISMA 2020 guidelines, reviewing English-language publications from 2014 to 2024. Editorials, duplicate reviews from the same journal, and papers lacking a DOI were excluded. The literature search was conducted using PubMed, SagePub, SpringerLink, and Google Scholar. Result: A total of 2,172 articles were initially identified through online databases (PubMed, SagePub, SpringerLink, and Google Scholar). After three rounds of screening, eight relevant studies were selected for full-text analysis. Conclusion: The cytologic atypia seen in CCLs, particularly in FEA, is a key diagnostic feature that distinguishes benign lesions from malignant ones. FEA lesions, characterized by low-grade cytologic atypia, including altered nuclear polarity and increased nuclear-to cytoplasmic ratios, retain the architectural features of CCC or CCH but with evidence of atypia.