Discordant biopsies---ADH and then no ADH? Clip migration?

[deepa]

Small area of clustered microcalcifications (3-4 o'oclock) on mammo prompted stereotactic core needle biopsy in 2/02.  Path results: no cancer, but focal ADH, fibrocystic changes with foci of papillary apocrine hyperplasia and stromal fibrosis; microcalc'ns seen on x-ray of tissue fragments.  Second path opinion confirmed results. Surgeon recommended open bx but agreed to close follow-up after much discussion, consult with medical oncologist, and my own research. Clinical BE, self BE, 6 mo. mammos done. No changes on mammos since.  2 cysts, too small to aspirate, noted in same breast (2-3 o'clock) since 3/03- observed every 2 mos. by MD- persisted but did not change by 7/03.  He was uncertain if they were in original area of concern, as clip seemed to be much lower and toward center of breast on mammo than where these were, and where microcal'ns had been observed to begin with.  Excisional bx with 2 incisions & specimens (6 o'clock for the clip, 2 o'clock for the cysts) done 9/03.  Path report: no cancer, NO ADH (!); fibrocystic changes- adenosis, sclerosing adenosis, microcalc'ns, mild to moderate usual intraductal hyperplasia, focally w/ apocrine features, columnar cell hyperplasia, cysts, apocrine metaplasia, & fibroadenomatoid hyperplasia. Wire & clip noted. Am now 55, became menopausal during this period.
1. How to explain no ADH in larger tissue sample from open bx (supposedly the "gold standard")?  Could possible clip migration lead to missing original area w/ microcal'ns & ADH at SCNB?  Wire needle loc was done to the clip.  If it had moved, surgeon may not have obtained tissue from "true" area of concern.  Also, incision was in different location than original microcal'ns and where he had said incision would be (3:00).  2. Would SCNB needle track be visible (grossly or microscopically) in specimens or on mammo to identify original area?  3. Would hormonal changes of menopause cause ADH to disappear? Does ADH come and go, as do cysts?  4. Is it possible that the only existing spots of ADH were removed with the SCNB?
What is your assessment? Should I get a second pathologist to review?  How would one pursue whether surgeon got true original area (w/ ADH) in the excision tissue?  Would further bx be warranted? (Believe me, I don't want to go there, but it seems like the issue of the possibility of cancer associated with ADH has not been resolved from this procedure).
Many thanks for this invaluable website, which helps women with breast conditions gain perspective and needed information.

[CCF-RN,MSN-rf]

Dear Deepa:  1.  The original pathology report said focal ADH.  Could be this was the focus.  Could also be that the area is not exact.  Mammogram should show whether there are residual calcifications or not but you need some time to heal.  Another method, if possible to identify, would be to do ductal lavage ro ductoscopy to the affected duct to monitor.  2.  To my knowledge track would not be visualized although scar tissue could give one a clue microscopically if any had formed.  3.  If all of the ADH was removed the first time, then there would be none left to disappear.  ADH can progress, regress or stay stable.  It is possible that if hormones contribute to its development, menopause could slow its growth.  4.  Yes, see #1.  

For your own comfort, you could get a pathology review.  However, as none of these things are cancer or even precancer, continued monitoring may be completely adequate.  A mammogram will tell you if additional biopsy is needed.  People with ADH are at higher risk for developing cancer but these things do not necessarily turn into cancer.  It simply indicates areas of overgrowth of cells with some atypia.