PASH Diagnosis but feel in my gut that something was missed

cmilliga17

Thank you in advance for listening! About 6 weeks ago, I found a small, hard mass on my outer upper left breast. I am extremely small chested (barely an A) and had never had a mammogram. In August, my GYN encouraged me to go for my first one since I had just turned 42. Because I noticed a lump, she changed my referral to a diagnostic mammogram with ultrasound. This mammogram was deemed inconclusive due to the density of my breast. The ultrasound tech only took about 4 pictures, said she didn't see anything, and sent me on my way. A few days later, my GYN called to encourage me to make an appointment with a breast surgeon. I fall in the "extremely dense category" (1/10 people) and have several family members who have had breast cancer, including a maternal aunt who was diagnosed at 35. Upon meeting the surgeon, she calculated my Tyrer Cusick score to be 25 based on my factors. She ordered an MRI with and without contrast. The MRI report was flagged as abnormal, showing "mixed kinetics" in the area where I can feel the palpable lump. The surgeon recommended I have an ultrasound guided core needle biopsy. At the ultrasound, the tech who was very experienced (had 39 years in the field) was clearly concerned with a few areas. When she called in the Radiologist to look and discuss continuing with the biopsy, the radiologist looked me right in the face and said, "Regardless of how this comes back, you need to have another MRI in 6 months". She performed the biopsy and took several samples. In my opinion, she was concerned. When the pathology report came back, it said the following:

The specimen is received in formalin in a container labeled with the patient's name and " left breast 2:00 4 cm from nipple bowtie clip". It consists of multiple irregular to cylindrical pale tan-pink to yellow soft fragments of fibroadipose tissue measuring 1.8 x 0.9 x 0.3 cm in aggregate. The specimen is submitted entirely in cassette A1.

Cold Ischemia time: 1 minute 24 secondsFinal Diagnosis:

Final Diagnosis

Left Breast 2:00 4cmfn, ultrasound guided core biopsy (bowtie clip): Benign breast tissue with focal PASH-like stroma. See comment. The radiologist added the following comment after she reviewed the findings: Pathology results may be concordant with the imaging appearance. Management per surgical oncology is recommended. In my interpretation, I feel like she wasn't agreeing with the report. Thoughts? Additionally, I thought that PASH was a very rare condition but it seems to be a diagnosis for a lot of people on here!!! I am concerned that she missed the area with the biopsy and the color of the tissue that was analyzed. Any thoughts would be appreciated! I'm driving myself crazy! I have 4 children, one of whom has autism, so I have to be super proactive! I am not in the "wait and see mode"; I would have a double mastectomy in a heartbeat if it was an option. Thank you so much!

exbrnxgrl

cmilliga,

PASH is uncommon but you are on a breast cancer discussion board. We all either have bc or other breast conditions or are awaiting testing results. Those who receive negative results simply stop posting so you can see that bco represents a very slanted view when compared to the population in general.
With respect to family history, genetically linked breast cancers are the minority of all bc cases. The figure most often given is about 15%. If this is a concern you may want to find out if you're eligible for genetic counseling and then testing.

As far as waiting goes, that is very common! If your current assessments show benign results, watching and waiting is perfectly reasonable. If that makes you really uncomfortable, you could always seek a second opinion. Iunderstand your anxiety as you have young children but a bmx (bilateral mastectomy) is a major surgery that is not without its own risks and complications that can be exacerbated if you have reconstruction. It's doubtful that any surgeon would remove healthy breasts without any justification and it's doubly doubtful that your medical insurance would pay for surgery that is not medically necessary. I realize you are stressed but in your position, wait and watch seems reasonable and definitely look into genetic counseling. Take care.

gamzu710

Is PASH that uncommon? This Cleveland Clinic article says it can be found in up to 23% of breast specimens: https://health.clevelandclinic.org/my-biopsy-shows-i-have-pseudoangiomatous-stromal-hyperplasia-pash-―-now-what/

I had a breast MRI following my cancer diagnosis in August that flagged 3 additional areas for MRI-guided biopsy. One was an "asymmetric clumped segmental non-mass enhancement" spanning up to 4.5 cm. My frantic Googling of these terms found scientific papers suggesting that these descriptors usually came back as DCIS is 90% of cases, but that the other 10% were usually PASH and benign. My biopsy came back as PASH and the radiologist deemed it concordant with imaging and recommended 6-month follow-up.

I initially had the same questions you had but the fact that my result did fall into one of the categories the literature suggested it would, even if that category was in the minority, made me feel a bit better. I will also say that the other 2 sites the MRI flagged also came back as benign (fibrocystic change and ductal ectasia) so just because they are "concerned" on an MRI image does not mean that something is actually wrong and was missed. MRI is very sensitive but does give more false positives. If the radiology report mentioned a surgeon, a consult might help you get more input and put your mind at ease.

exbrnxgrl

I wouldn’t say PASH is rare, but uncommon, yes. 77% of the breast specimens didn’t contain it! However, words like rare and uncommon are highly subjective so uncommon to me may be common to someone else.

AliceBastable

And neither "rare" nor "uncommon" means "bad."

BCat40

if she is saying management through surgical oncology it could mean an excisional biopsy, which is essentially the same as a lumpectomy but then they get the whole area of concern out for a biopsy rather than just what comes up in the needle.