Topic: Help! Surgery Rec. but Dx is Unclear - what advise to follow

The only way they can really diagnose breast cancer is by biopsy (looking at cells under the microscope.) Fine needle biopsies can distort the shape of cells and make it harder for the pathologist to read.


You may want to check out this. http://www.pathologyoutlines.com/breast.html#papilloma I think that getting your slides reread and/or new samples are a good idea. MRI can pick up a lot of junk, but again is not 100% definitive. Just like everything in bc.

Like pink said, I'd be very careful.

ellismre, do you know if the "needle biopsy" was a fine needle aspirate, or a core needle biopsy?  There is quite a difference in the quality of the sample obtained with those two techniques.  In either case, though, you might be looking at a surgical removal of the tissue, because either biopsy method could miss crucial areas of the abnormal tissue (more about that, later).

If the radiologist who took your biopsy was unable to obtain a diagnostic sample, you may have several options, but they are not equally helpful:  1) have a different pathology lab read the slides that were made from your original biopsy; 2) have the tissue biopsied again, in hopes of getting a better sample; 3) have the lump sampled surgically (incisional biopsy--takes just a slice, not the whole lump); or 4) have the entire lump removed surgically.

You said this:  "I got a 2nd opinion at UCLA who rec. a breast MRI.  Also they said it was strange for the radiologist to not conclude if it was cancer or not since that would effect the type of surgery - i.e. how much to remove in terms of "margins" etc.  She rec. that I bring the slides them and have them reviewed.  Should a radiologist/pathologist be able to conclude if it is cancerous or not on the needle biopsy?"

The radiologist just collected the samples.  A pathologist prepared the slides and examined them microscopically.  The pathologist is the person who determines whether the cells he/she sees are malignant or not, and he/she will write that into the report.  The radiologist must depend on the pathologist's judgment of whether the tissue contained cancerous cells--that is not something the radiologist can determine.

As for the size of the tumor (if there is one) and the amount of tissue that would need to be removed, that can sometimes be estimated with imaging studies like mammography, ultrasound, or MRI. A contrast breast MRI might be helpful in deciding how big the abnormal area is, and whether there are other suspicious areas in that breast or in the other one.

I found a technical, but very good, article about papillary lesions of the breast, and the problems involved with determining whether they are cancerous.  The article was in the journal, "Histopathology", vol. 52, pages 20-29.  It was published in 2008 by two people from the Department of Pathology at Beth Israel Deaconess Medical Center & Harvard Medical School. Here's a link to the article in pdf format:  http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1365-2559.2007.02898.x 

The very first paragraph of the article says this:  "Surgical pathologists generally have little difficulty in identifying a breast lesion as papillary based upon finding a proliferation characterized by finger-like projections or fronds composed of central fibrobascular cores covered by epithelium. However, once identified as papillary, the categorization of the lesion as benign, atypical or malignant is often problematic, even for experienced pathologists. Furthermore, even when recognized as a carcinoma, it may be difficult to determine if a papillary lesion is in situ, invasive, or a combination of the two."

That's why your diagnosis is unclear.  It's not the radiologist's fault; nor is it the pathologist's fault.  It's just a very confusing type of lesion to have. BTW, the phrase, "intraductal papillary neoplasm" means the abnormal cells the pathologist saw in the biopsy sample were within the ducts of the mammary tissue--they had not escaped into the surrounding tissue, much less to the lymph nodes. So don't worry about that, at least not yet. It still might be necessary for the abnormal tissue to be removed surgically, though, because the diagnosis is so confusing and it's hard to tell from just a needle biopsy whether there were other, unsampled areas that were invasive.

Here's what that Histopathlology article says about surgical removal:  "There is universal agreement that surgical excision is required when an atypical papillary lesion or papillary carcinoma is present in a core needle biopsy specimen. However, the need for surgical excision in patients in whom a benign intraductal papilloma is found on core needle biopsy samples is an unresolved issue.  The concern is that if an excision is not performed in such cases, areas of atypia or carcinoma may be missed in the limited sample afforded by core needle biopsy."

So, it was good to get that 2nd opinion.  If it turns out to be different, though, you'll need to decide who to believe, and that's the hard part.

otter 

After diagnostic mammos, ultrasound and needle biopsies were inconclusive, and worse negative in the case of the biopsies, the breast MRI ruled out any problem with my right breast and confirmed that there was something going on in the left.  The incisional biopsy cinched it but if it hadn't have been for the MRI, if I'd left it at the results of the needle biopsies, I'd be in pretty bad shape now as I did have a 4.5 cm IDC tumor in the left breast.