Comments on: ADH vs. DCIS

By: drlawton

drlawton — Tue, 10 May 2011 23:21:05 +0000

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.

By: ssadowski

ssadowski — Tue, 10 May 2011 10:36:25 +0000

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.

By: drlawton

drlawton — Sun, 17 Apr 2011 16:51:39 +0000

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.

By: rita

rita — Sun, 17 Apr 2011 06:35:35 +0000

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.

By: drlawton

drlawton — Sat, 16 Apr 2011 22:09:29 +0000

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.

By: rita

rita — Sat, 16 Apr 2011 13:31:38 +0000

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.

By: drlawton

drlawton — Sun, 21 Nov 2010 00:13:55 +0000

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?

By: Lindsey

Lindsey — Mon, 18 Oct 2010 15:26:41 +0000

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!