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Interpretation of breast biopsy specimens (02HDC08200)

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(02HDC08200, 8 January 2004)

Pathologists ~ Standard of care ~ Breast screening ~ Multidisciplinary panels ~ Right 4(1)

A woman diagnosed with Grade 1 infiltrating ductal carcinoma of the breast complained that two pathologists had misread her core biopsy and hookwire biopsy samples, both of which were reported as complex sclerosing lesions.

An abnormality was discovered in the patient's upper right breast following a routine screening mammogram and an examination by a breast physician. As a result, ultrasound-guided core biopsies were taken and sent for reading. The pathologist who reported the biopsy stated that she considered the possibility of a malignant lesion and proceeded to perform immunohistochemistry on the specimen. On interpretation it appeared to be benign and representative of a complex sclerosing lesion. However, because the lesion was complex and difficult to determine, follow-up hookwire localisation and biopsy was recommended.

The specimens from the hookwire biopsy were interpreted by a different pathologist, who noted increased fibrosis and groups of distorted ducts, compatible with a complex sclerosing lesion. He indicated that he was not entirely confident of the diagnosis and obtained confirmation from immunohistochemical stains.

All the findings were reviewed, in accordance with normal protocol, at a multidisciplinary meeting. It was agreed that all the presenting features of the lesion were "concordant with the histological finding of a complex sclerosing lesion". The patient was advised to have a routine screen in a year's time.

The patient's GP referred her to an alternative breast screening service for her next mammogram. Clinical examination was normal, and the X-ray showed no evidence of malignancy. As per normal procedure at the alternative breast screening service for a patient with such a history, all the patient's radiology and histology findings were reviewed at the weekly multidisciplinary meeting. The pathologist who reviewed the slides found a Grade 1 infiltrating ductal carcinoma. The patient subsequently underwent a partial mastectomy and axillary node dissection. No residual or recurrent tumour was found.

It was held that neither of the original reporting pathologists breached Right 4(1) of the Code. The original pathologist had provided services with reasonable care and skill in immunostaining the specimen and referring for further examination when she found it difficult to interpret. The second pathologist had reported that he was uncertain of his conclusions and carried out further immunohistochemistry; it appeared that he had examined the samples very closely and arrived at well-considered conclusions. In doing so he was not in breach of the Code. Histological interpretation is an area in which pathologists sometimes agree to differ.

 

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