The complexities of diagnosing ADH vs. DCIS

[Gut Shot]

That is all.

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[djmd]

Man do not start this up already.
And yes, yes I can.

 

[Gut Shot]

Everything you need to know about ADH vs. DCIS:

1. Intraobserver reproducibility is poor, which is disappointing
2. Breasts are modified sweat glands, which is even more disappointing

 

[docbiohazard]

2. Breasts are modified sweat glands, which is even more disappointing

This reminds me of the very excellent histopath prof I had in 1st year, who made the same statement in his lecture on mammary tissue. He was a great teacher, and unfortunately passed before his time.

Still brought a smile to my face.
BH

 

[Gut Shot]

This reminds me of the very excellent histopath prof I had in 1st year, who made the same statement in his lecture on mammary tissue. He was a great teacher, and unfortunately passed before his time.

Still brought a smile to my face.
BH

That's who I got it from (circa 1995). He was quite a guy.

 

[deschutes]

3. Prostate is like breast, but prostate is easier. (Also no re-excisions!)

 

[1Path]

1. Intraobserver reproducibility is poor, which is disappointing
2. Breasts are modified sweat glands, which is even more disappointing

Gee, sounds complex.

......For me, I think I have settled on breast path. The ADH vs DCIS differential drives me batty, and lobular lesions drive me batty, and microinvasive cases drive me batty. Plus, all these things on "is it atypical or not" drive me crazy. I almost feel like at least 25% of breast cases would make me wish I had an expert consultant if I was signing it out, and I don't get to this level with anything else.........Breast path I feel like I can get a gestalt after a second or two but even if I stare at it for an hour and read chapters in Rosen or Tavassoli I will still be clueless.............Breast path it seems like the criteria make no sense (or at least are not that readily applicable) yet experts tend to agree on more tough cases. And it also seems like the clinical issues if you are wrong in breast path are more immediate and dangerous.

Undoubtly, the best pathologists will likely continue to be those can admit to challenges in the profession, and it's these folk from whom much can be learned.

Signed, A future Breast and GU Pathologist

 

[Gut Shot]

Signed, A future Breast and GU Pathologist

We'll leave the light on for you.

 

[Gut Shot]

Gee, sounds complex.

I must say, your end of the discussion isn't being held up very well.

 

[yaah]

Breast path challenges seem so arbitrary though. Other differentials in other organ systems are difficult yet they mean much more. The low grade DCIS vs ADH differential (when it is tough) doesn't really mean anything. They are both risk factors for invasive disease somewhere else in the lesion and warrant excision. I feel like needle biopsies should have a choice of three diagnoses in breast path:

1) Cancer. Reexcise and start planning treatment now.
2) Atypical. Reexcise and see what that shows.
3) Benign.

Pathologists struggle all the time on needle biopsies about whether something is ADH or low grade DCIS, but it doesn't really matter! If you reexcise there is something more substantial so you can make the diagnosis, or alternatively there is nothing left and it's already out at that point.

 

[djmd]

Pathologists struggle all the time on needle biopsies about whether something is ADH or low grade DCIS, but it doesn't really matter! If you reexcise there is something more substantial so you can make the diagnosis, or alternatively there is nothing left and it's already out at that point.

I was actually thinking the same thing. The clinical difference between those two is of limited importance...

 

[yaah]

I was actually thinking the same thing. The clinical difference between those two is of limited importance...

The main problem (I think) is that pathologists can disagree on this distinction, and it's fine, other pathologists won't really object too much or will understand the difference of opinion. But to a patient it is crucial. Either it's "cancer" or it isn't. I have met patients who have "only" DCIS and call themselves cancer survivors, but you can't call yourself a cancer survivor if you have ADH. So while the distinction is arbitrary, subtle, vague, and even reasonable, the consequences may not be. Surgeons may treat a diagnosis of ADH on core bx the same way they treat a dx of DCIS, but there is a huge difference to the patient.

 

[djmd]

T I have met patients who have "only" DCIS and call themselves cancer survivors, but you can't call yourself a cancer survivor if you have ADH.

A pre-cancer survivor? (if DCIS get to take cancer survivor)
A pre-pre-cancer survivor? (if cancer patients get wind of the DCISers and make them stop)

Of course it is shades of grey and how the patient wants to view the shades depends on their point of view and frame of reference... compared to fibrocystic change, ADH is black. Compared to Cancer it is white...

 

[1Path]

I was actually thinking the same thing. The clinical difference between those two is of limited importance...

Unless of course, you or someone you love is dealing with the diagnosis.

I must say, your end of the discussion isn't being held up very well.

And I must say, that you don't know jack **** about breast path. You'd better get yourself a good malpractice lawyer NOW.

 

[yaah]

And I must say, that you don't know jack **** about breast path. You'd better get yourself a good malpractice lawyer NOW.

He didn't say anything that isn't valid. Interobserver reproducibility IS very poor. He didn't even say anything else.

Please stop being deliberately confrontational. I don't want to keep closing threads.

 

[l&usibari]

Unless of course, you or someone you love is dealing with the diagnosis.
And I must say, that you don't know jack **** about breast path. You'd better get yourself a good malpractice lawyer NOW.

I think we're getting a bit tired of you, 1Path. Please play nice or go away.

 

[djmd]

Unless of course, you or someone you love is dealing with the diagnosis.
And I must say, that you don't know jack **** about breast path. You'd better get yourself a good malpractice lawyer NOW.

Your first statement is meaningless. If we were talking about a stock market crash, and I said "well the 10% loss of stock X is not that important", the counter "unless someone you love/know is blank" (blank being ceo, unemployed due to, unwisely invested life saving on margin in)

Of course, personal proximity changes the perceived importance. It doesn't change the clinical picture.


And you claiming that other people don't know about breast path, is a little pot-kettle. You haven't even gone to medical school. And while I'm sure if your research involves looking at breast tissue, you may think you have a good handle on breast pathology. But could you look at a lung cancer met to breast and identify it? How about Plasmacytoma?

You aren't a pathologist or a pathology resident, your ability to judge people here is limited.

 

[1Path]

And you claiming that other people don't know about breast path, is a little pot-kettle..

WTF are you talking about? I didn't say "people" don't know about breast path, I wa sreferrig ot Gun Shopt comment below. Unless of course, you all also agree with this statement too.

I must say, your end of the discussion isn't being held up very well.

Maybe that idea of taking a statement of mine about DCIS and ADH to prove me wrong, didn't quite work as well at Gun Shot intended.

You haven't even gone to medical school. And while I'm sure if your rese
arch involves looking at breast tissue, you may think you have a good handle on breast pathology........You aren't a pathologist or a pathology resident, your ability to judge people here is limited....

I beleive they call people have a natural propensity for things they haven't yet learned/practiced in great detail, naturally talented (although I did get an "A" in Medical Pathology).I've haven't been to med school yet? Gee, I'm glad you cleared that up for me. I haven't yet gone to med school however, I managed to learn enough from a few of the best paths in the US, to know that ADH versus DCIS differential IS complex. I don't judge who I can and cannot learn from. Too bad you do.

But could you look at a lung cancer met to breast and identify it? How about Plasmacytoma?.

Given that I have only taken 1 path coure WITH med students and haven't yet completed a residency in path, of course not but trust me just like YOU learned it, I CAN TOO. Can you tell the difference between oncocytoma and renal cell carcinoma? Do you know the difference between tangles and plaques and I mean structurally, what proteins are involved, where they're located? I mean what's the purpsoe of this whole "do you know stuff"? Of course there are thing's you know that I don't. But guess what? I'm SURE there's plenty of stuff that I know that you don't just like there's a TON of stuff my Accountant knows that neither of us knows. So what't the point, really?

Yaah, perhaps if your egotistical collegues had NOT resorted to personal attacks to make a point in the internet, I wouldn't need to be so confortational. MD's aside, I'll defend my point of view despite the asinine name calling.

 

[sequela]

ummm........sh'e not even in MEDICINE!!!!!!

 

[1Path]

ummm........sh'e not even in MEDICINE!!!!!!

You're right, I'm actually a Buddist monk, who teaches belly dancing and yoga to Catholic priests in the evening. For relaxation, I take courses in Med Pharm, Med Biochem, Med Path, and Histology.And those breast cancer patients I see in the clinic keeps me from sipping Mimosa's all day with other SAHM's.

 

[docbiohazard]

I just started my psych rotation this week, and I have to say this forum is turning into a co-curricular activity...

Look out now, here it comes...

BH

 

[djmd]

WTF are you talking about? I didn't say "people" don't know about breast path, I was referring to Gun Shops comment below.

1. Intraobserver reproducibility is poor, which is disappointing
2. Breasts are modified sweat glands, which is even more disappointing

Unless of course, you all also agree with this statement too. Maybe that idea of taking a statement of mine about DCIS and ADH to prove me wrong, didn't quite work as well at Gun Shot intended.

Robbins pg 1120 "The class Mammalia is remarkable for the evolution of modified skin appendages that provide complete nourishment ...." (skin apendages = sweat glands)

So, yes, Myself and Lester SC, and Kumar, Abbas, Fausto, all seem to agree with Gut shot. And you said that ADH vs DCIS is challenging so I guess you agree that intraobserver reproducibility might be less than great.

But guess what? I'm SURE there's plenty of stuff that I know that you don't just like there's a TON of stuff my Accountant knows that neither of us knows. So what't the point, really?

Yaah, perhaps if your egotistical collegues had NOT resorted to personal attacks to make a point in the internet, I wouldn't need to be so confortational. MD's aside, I'll defend my point of view despite the asinine name calling.

Yaah, closed that thread, and people have not been name calling in this thread. The other thread closing was to serve as an indicator that everyone should cool their jets.

And the point is "A man has got to know his limitations." You are arguing with people who have training in this field, while you at best have specific exposure to this issue (pathology of ADH vs DCIS). I specifically picked breast pathology related topics to prove my point, not something esoteric. The majority of people here are pathology residents or attendings, they have training in pathology as a whole. You do not know anyone else here, their level of training, who has trained them, or even where some of them work. To accuse people here of being bad pathologists is AT BEST ill-conceived, and at worse libel, slander, and name calling.

 

[yaah]

Yaah, perhaps if your egotistical collegues had NOT resorted to personal attacks to make a point in the internet, I wouldn't need to be so confortational. MD's aside, I'll defend my point of view despite the asinine name calling.

You can't resort to name calling to confront what you think is asinine name calling. And since this entire thread has once again degenerated into you vs the world, I would question who the egotistical one is.

May I make a suggestion? Your exposure to pathology has been limited thus far, but you obviously have valid and important life experience and have exposures to areas of pathology that others do not. And you have an interest in pathology and/or research as a career, which is admirable. So try not to use your limited experience to claim to be an expert on so many things, or claim that your experiences are somehow more valid (either because of hearsay, your past experiences, or because of your future goals). By all means, express your opinions and ask questions, that is what we are here for. But we are not hear to witness virtual arguments over language, terminology, and insults perceived or unperceived. No one else is interested in that unless it is funny or amusing, which this is not.

Now, no more posts about who was or was not asinine in their name calling. It's irrelevant and silly.

 

[1Path]

And since this entire thread has once again degenerated into you vs the world, I would question who the egotistical one is.........So try not to use your limited experience to claim to be an expert on so many things, or claim that your experiences are somehow more valid (either because of hearsay, your past experiences, or because of your future goals)

First, I appreciate the mature response but then that has never been a problem between you and I no matter what we're debating/discussing in the internet.

However, I haven't claimed to be an expert on anything and you can't find ANY of my posts in this forum which ellude to such a ridiculous premise. I only claim to know what I know which isn't much comparitively speaking anymore since I don't get the day to day exposure to path I used to get. But I am lucky that the path residents/faculty at the school I currently attend appreciate my questions/comments at in house path conferences however huberous they may occasionally be. And THIS is what education is supposed to be all about.

I also think that it's important to note that the purpose of starting this thread wasn't to have a real discussion about ADH versus DCIS yet I have seen NO reprimand sent that way. I understand you guys are collegues and I'm just a "lowly future doctor", but where I come from wrong is wrong no matter what letters you have behind your name.

 

[djmd]

I also think that it's important to note that the purpose of starting this thread wasn't to have a real discussion about ADH versus DCIS yet I have seen NO reprimand sent that way. I understand you guys are collegues and I'm just a "lowly future doctor", but where I come from wrong is wrong no matter what letters you have behind your name.

Actually I did, second post I told him not to start his up already. And It actually was turning into a rather good discussion about ADH vs DCIS.

The point about people here being residents is not some attempt to lord MDs over you, but a reminder that the people you are talking to most likely know about this topic.

In this topic you got all fired up because of Gut Shot's (simplistic but correct) statement. Or rather because of an interchange baised on that statement, to which you retorted "that you don't know jack **** about breast path. You'd better get yourself a good malpractice lawyer NOW."

There was nothing false in Gut Shot's original statement...

" Education is the ability to listen to almost anything without losing your temper."

You said "But I am lucky that the path residents/faculty at the school I currently attend appreciate my questions/comments at in house path conferences"
Try asking questions here, and not telling us answers.

 

[1Path]

There was nothing false in Gut Shot's original statement...

" Education is the ability to listen to almost anything without losing your temper.".

So this only works one way, to those without an MD? Well then I must have struck gold twice because in my second experience with path residents, you don't need an MD to qualify for making a valid point.

You said "But I am lucky that the path residents/faculty at the school I currently attend appreciate my questions/comments at in house path conferences"
Try asking questions here, and not telling us answers.

If I have a question, then I'll ask and here's an example:http://forums.studentdoctor.net/showthread.php?t=396625

If I have a statement to make, then I'll make one. If you agree or if it's way off say that, but it isn't necessary to remind me of where I am in the educational process and make insulting comments to get your points acroos since doing so makes a person insecure IMHO. The residents and MD's I'm around seem to get their points across just fine without resorting to such behavior.

 

[djmd]

If I have a statement to make, then I'll make one. If you agree or if it's way off say that, but it isn't necessary to remind me of where I am in the educational process and make insulting comments to get your points acroos since doing so makes a person insecure IMHO.

In both this thread and the closed one, you have started the insulting comments game.

I'm curious, is residency going to be or already is your first "real" job?

Which makes your complaint about people reminding you of where you are in the educational process seem strange. That is exactly what you attempted to do in the other thread.
It is what you implied about Gun Shot earlier, you attempted to imply that someone else's education or understanding was faulty.

You are specifically doing to other people exactly what you don't want done to yourself.

 

[deschutes]

Time to cease and desist, folks. Keep to the relevant topics or the thread will be closed.

Also remember that users have available to them the "Report Post" and "Ignore List" functions.

 

[Gut Shot]

Hey, guys! Just got back from a surgical pathology conference... what did I miss?

Oop, off for 10 days of vacation! Ciao!