ADH vs. DCIS
I wanted to take some time to write about one of the most challenging areas in breast pathology and one that I receive countless questions about–distinguishing atypical ductal hyperplasia (ADH) from ductal carcinoma in situ (DCIS). While this may seem like an academic issue that doctors argue about it has MAJOR clinical implications for patients.
Atypical ductal hyperplasia refers to a proliferation of cells in the breast ducts that doesn’t quite meet all of the criteria for low grade ductal carcinoma in situ. While I am para-phrasing, this is basically the definition that exists in the pathology literature. The problem for pathologists is that this definition is very subjective. There have been several studies that show that pathologists frequently do not agree on whether a certain biopsy is ADH or DCIS (if you are interested I can email you the references). The bigger problem for patients is that your doctors will recommend completely different treatments depending on whether your pathologist diagnosis ADH or DCIS.
For example, if you have a lumpectomy and you receive a diagnosis of ADH then your surgery is complete; your pathologist doesn’t need to comment on the surgical margins and radiation therapy is not recommended for ADH. However, if your pathologist makes a diagnosis of DCIS then you are diagnosed with “breast cancer” and your surgeon will want to know 1) if he/she got clear margins on the DCIS and you may need additional surgery; 2) your medical oncologist may ask the pathologist to determine if your DCIS is estrogen receptor positive so you can receive anti-estrogen therapy; and 3) you may be referred to a radiation therapist to get radiation to your breast.
So you can see why this distinction is so important to patients. If you are confronted with a diagnosis of ADH or DCIS, make sure that you find out if your pathologist has a lot of experience in breast pathology or get a second opinion on your biopsy. It can make a significant difference in what treatment, if any, your doctors recommend.
If you are interested, I have a tutorial on breast pathology and in the first installment I talk about ADH and DCIS and show some images of how they can look very similar under the microscope.
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I am a current pathology resident (first year) and wanted to know your opinion about a residual ADH close (<1 mm) to resection margins. I was reading about a study that came out in 2008 that suggested that it was necessary to go back to resect positive/close margins with residual ADH due to chance of recurrence, etc. Thanks so much!
I apologize for not responding earlier–some comments have not been getting to my mailbox and are being filtered out. Generally, pathologists don’t comment on ADH at margins and surgeons don’t usually go back to resect a margin if there is ADH near it. Do you have a reference for the study you mentioned?
Dear Dr. Lawton,
Last March 2011, my doctor found 2 suspicious calcification on my right breast during mammogram. This was immediately followed by stereotactic biopsy. Histopathology report a: right side superficial: DCIS (DIN2), b: right side deep: no malignancy of DCIS microcalcification is present. I had surgery two weeks later to remove the calcifications and histopathology report says: ’sections show two clusters of microcalcification within atrophied breast acini and hyalinised fibroadenomatous nodule with residual atypical ductal hyperplasia and florid usual ductal hyperplasia seen on the sections taken from the bases of hook wires. There is fibrocystic change in the fibrotic area. No residual ductal carcinoma in situ or invasive components is seen. The margins are free of microcalcification or dysplasia’. My question is will my treatment be for ADH since my doctor explained that all dcis was removed during biopsy? Thanks you very much.
If the DCIS was removed and only ADH is left you should be done with surgery. The question is how large an area of DCIS was present in the initial core biopsy, what grade (sounds intermediate if it said DIN 2) and was their necrosis? Also, did they stain the DCIS for estrogen receptor? These things may dictate whether your doctor would recommend anti-estrogen therapy and radiation therapy to the breast. I hope this helps. Feel free to write back if that didn’t answer your question.
Thank you very much for your response. My histopathology report does not say the measurement for the DCIS since none was taken during WLE. My doctor explained to me that the DCIS was too small to measure. My doctor then requested for IHC stains from the biopsy taken prior to surgery and the report came back with ER & PR positive. No necrosis grade 2. I will be turning 51 years old this year.On my first visit to my oncologist, I was told I need radiotherapy + tamoxifen. However, on my second visit, I was able to query him regarding the treatment against the very small DCIS taken during biopsy. My oncologist then explained the Silverstein study to me and if based on the Van Nuys prognostic index then I would have attained a low score of 5. He then told me that I may choose not to go for radiotherapy but he would like me to go with tamoxifen. I then asked him if it is the best treatment for me but he is leaving that decision to me. I have searched high and low as to whether the radiation side effects outweigh its benefit. I was told that one of the benefits of radiation on the whole breast is it kills other bad cells that have not been found on mammogram and ultrasound. Would it be appropriate not to take radiotherapy at this time? I have greatly appreciated your response.
Given that the small amount of DCIS is ER positive, it is reasonable to recommend tamoxifen based on the NCCN Guidelines. The issue of radiation therapy is still debated in the breast care community. Some feel all DCIS should be radiated to reduce the risk of recurrence while another school of thought believes some types of DCIS (mainly small, non-high grade, non-necrotic) DCIS can forgo radiation therapy as the risk of recurrence is so low. I wish I could tell you the right way to go but as your doctor said it’s really your decision after you weigh the pros and cons. I posted an article in my blog a little while ago regarding the use of partial breast irradiation vs. whole breast irradiation if you want to read that (it’s from the journal Cancer). It may then offer some links to prior studies talking about the benefits and risks of radiation that might help you make your decision.
Hello, and thanks for taking the time to answer my questions.
March 29th first biopsy done, clinical information and history: Bloody nipple discharge left breast for 20 months, papilloma suspected, mammogram clear. Diagnosis after excision: 1. Low grade DCIS 2. Focal proliferative fibrocystic changes and small intraductal papilloma 3. DCIS focally transected by excision margin. ACIS: ER 99%, PR 2%, done on a 61-year-old woman in good general health. Duct and lobe removed, no node needed. Told Stage 0, Grade pre-cancer
Recommendation: Mastectomy, radiation 5 wks, Arimidex for 5 years. Re-excision
April 22nd second excision done: 4 sections removed: MEDIAL margin: ADH, no malignancy, medial margin negative for malignancy. CRANIAL margin: low grade DCIS, In Situ carcinoma extends to inked & cauterized new cranial margin. LATERAL margin: low grade DCIS, margin negative for malignancy (tumor free margin less than 1.0MM) CAUDAL margin: benign tissue with biopsy site changes.
Recommendation: Mastectomy, radiation 5 wks, Arimidex for 5 years, possible Re-excision
Second excision introduces ADH, does this mimic DCIS? My confusion comes from the label of IN SITU, meaning in place. If the cells are IN SITU, why are they asking for more tissue? Are the ducts very close or more like mesh? Is a mastectomy really correct? Why are they asking for radiation and Arimidex even if they remove the breast? Can I have samples sent to you? Who would be good for a second opinion in the mid-west (NE)? Maybe what I need explained are the label of margins.
Thank you for your comment. Unfortunately, we thought this was an Ask the Pathologist question so your question along with my response was posted under that part of the website. Apologies for the confusion.