Question:  I was recently diagnosed with Low Grade DCIS via pathology report from my local hospital. My doctor was able to refer me to a very reputable breast clinic and I underwent a comprehensive work up on both breasts based on the outside pathology report for low grade DCIS in the right breast. The mammograms (and repeated) show the area is very large in the right upper quadrant (breast6.9 x 5.9 3.) The pathology report took a long time to complete from this center and they sent for the block. The results came back as ADH in benign duct. Because of the large area involved I am still being referred to a breast surgeon and plastic surgeon at this comprehensive breast center with consideration of an excisional biopsy versus mastectomy. My question is how can we know for sure which pathology report is correct. What if I had not sought another opinion? What are my treatment options?

Answer:  Thank you for contacting us.  The distinction between ADH and DCIS is often problematic. From your question and your mention of a possible excisional biopsy vs. mastectomy I am assuming your original diagnosis of low grade DCIS was made on a core needle biopsy.  If this is the case, even if the pathologist at the cancer center to which you were referred did not call it DCIS but ADH, based upon the current literature it would be standard to do a surgical biopsy to rule out a more significant lesion.  Thus, it appears you would need some sort of surgical intervention at this point, but the question is whether you get an excision vs. mastectomy. Based on this, I am not sure getting a second opinion at this point would change your need for surgery unless that opinion differed completely from the prior two by calling your core biopsy completely negative without any atypia. My concern is that with a diagnosis of ADH alone on a core biopsy without a definitive diagnosis of DCIS, a mastectomy seems radical.  It may be that they are offering that option due to the size of the area in question.  When you said “the area is very large in the right upper quadrant” based on mammogram, was this referring to extent of calcifications or were there no calcifications within the target lesion? ADH and other non-cancerous lesions can be associated with calcifications, so I would want to have the pathologist discuss with the breast imager and the surgeon what he/she saw on the core biopsy, why it was called ADH and not DCIS, and how extensive this process was on the core biopsy prior to committing to a mastectomy.  That being said, if you and your doctors decide on excisional biopsy and a diagnosis of DCIS is rendered and there is concern that there may be more DCIS within this area in question, you may require additional surgery or mastectomy to achieve clear margins.  At that point, if there is any concern of ADH vs. DCIS in the excisional biopsy, it may be prudent to seek a second opinion as further treatment decisions would change significantly.

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