Discordant biopsies--ADH and then no ADH

[deepa]

Thanks for reply and suggestion of ductal lavage; that hadn't come up about this so far.  I understand the risk but "not determinant" aspect of ADH.  I plan to discuss this and a path review with my surgeon.  

In your center's experience, or if you know from the literature, what proportion of the time does it happen that core needle biopsy (actually in my case vacuum-assisted device, Mammotome, was use) shows ADH and subsequent surgical open biopsy does not find any?  Is this finding pattern rare, sometimes, often, very often?  Would the lack of concordance between the two biopsies raise questions?

It seems there is not a lot understood about what triggers development of ADH and whether it tends to be highly focal or more generalized, as other cell types seem to be with fibrocystic condition.  There also seems to be a bias in the literature that focuses on ADH followed by or co-existing with cancer, which is understandable.  But what about the thousands of women who have ADH that is not turning into cancer?  Sometimes it is hard to reach a balanced view of the broader picture with so much emphasis on pathology vs. existence of ADH among healthy women.

Sorry this follow-up is delayed; it has been hard to get back in to the forum to post.

[CCF-RN,MSN-rf]

Dear deepa:  In response to both your first post and this one. It appears that the focal ADH was probably real since it was confirmed by two separate readings.  However, the only way to determine if the areas were similar would be to view the films.  Even then, it may be challenging.  In our experience we haven't seen clip migration but have seen needle loc migration. Clips are usually deployed to allow the surgeon to identify where he or she was originally.  The bottom line is that ADH was found and future care should be planned accordingly.  The negative larger excision merely confirms that there is no additional pathology.  Some physicians consider ADH a precancerous lesion, others say not.  Nevertheless, its presence increases a woman's risk of developing breast cancer 5 fold. Ductal lavage and ductoscopy would only be of benefit if the duct in question were able to be identified.  There would be no way to identify the duct involved at this point in time.  However, there may be a role for this if you develop new nipple discharge or other symptoms as part of monitoring.  Based on the information you provide, you fall into the high-risk group and should be surveilled accordingly.

[surgeon]

as a comment, but not direct answer to your question, I'd say these things: first, ductal lavage is much less definitive than looking at a block of tissue. Second, it would be useful to know if the same pathologist looked at both specimens. Third, ADH, as you already know, is not cancer. When a woman is diagnosed with it, the usual advice would be to continue a regular careful screening program. This would be true based on the first biopsy, regardless of the second. The reason for the second biopsy was to be sure no cancer was found in the area. This issue is to what extent it's possible the first area was not properly sampled in the second biopsy. I'd suggest directly asking this of your surgeon and radiologist. I'd guess neither could say without any reservation that it's been done perfectly, but that is true of many biopsies (to the extent that one would hesitate to say there's no way on God's green earth that it's impossible.) So the bottom line is do you feel the need to have an open wider biopsy, and what is the feeling of your doctors about that option? And then, what is your feeling about the answers you receive?

[deepa]

Would you be able to comment on the frequency of occurrence of this type of situation?  That would be helpful to me in considering the situation and making my own assessment of the responses I get.  (Please see my previous post, where I had posed the question.)  I appreciate your feedback, including the thought that it comes down to degree of comfort with my surgeon's response and the idea of another biopsy.  Monitoring had been the  strategy to begin with after the first dx of ADH, and even if the original site was missed, hopefully monitoring would still be effective in picking up any changes suggestive of possible cancer.  Another way to think about the second biopsy result, if the orignal site had been missed, is that it shows that there is no evidence of either cancer or ADH in other areas, so that is good.  Many thanks for your time.