Path report, what does it all mean?

Anonymous

Hello all of you wonderful ILC ladies.  I haven't posted for awhile on this board, I'm going through chemo, and I have been on the chemo board, or just out of it.  I have read a bit of discussion on the ILC board, but like I said, I've been out of it.  I finally asked for a copy of my path report,and I have a few questions.  You all have so much information, I hope you can help me be sure I'm not missing anything.  Okay, here goes, I'm going to put in the medical lingo, and then ask questions at the bottom.

Breast, left, simple mastectomy:

Invasive lobular carcinoma, pleomorphic variant.

Location of tumor:  Approximately 10 o'clock position

Margins:  Margins of excision are uninvolved by invasive carcinoma

Size of invasive carcinoma: 1.5 cm greatest dimension, as measured on the glass slide.

Extent of Invasion:  The tumor invades the lower aspect of the dermal collagen of the skin.  No dermal lymphatic Invasion identified.  No evidence of Paget's disease of the epidermis.

Vascular Invasion:  Vascular/lymphatic Invasion is not identified.

Perineural Invasion: Is identified

Microcalcifications:  Microcalcifications are focally present in relationship to invasive carcinoma.

Multicentriec lobular carcinoma in situ and atypical lobular hyperplasia.

Location of tumor:  Adimixed with invasive carcinoma, relatively minor component.  Involving a lactiferous duct ("pagetoid" spread).  Multicentric involvement of all quadrants of the parenchyma by foci of lobular carcinoma in situ, atypical lobular hyperplasia, and foci of "pagetoid" ductal spread.  With involvement of small ducts (solid pattern). 

Then in a further description of an ultrasound guided biopsy that I had in May:

Invasive duct carcinoma, combined Intermediate grade II of III.  ER 90%, PR30%, Her2 neg 1+

Although this invasive tumor shows few foci suggestive of lobular infiltrative pattern, the overall findings are more in keeping with an invasive duct carcinoma.  This assessment is supported by the presence of focal neoplastic ducts, the degree of nuclear pleomorphism, and the focal definitive positive reactivity for e-Cadherin.

Then there is this description of an excisional biopsy I had first:

In the currently described specimens, the in situ and the invasive tumor react essentially negatively on e-Cadherin stain and positively upon review of 34BE12 special stain.  These reaction patterns, along with the morphologic features, fit best for lobular origin of this malignancy.

According to the literature, the pleomorphic variant of invasive lobular carcinoma appears to share molecular genetic and immunophentypic characteristics of other forms of lobular carcinoma, although it  appears to have an increased frequency of adverse prognostic characteristics such as higher nuclear grade and higher frequency of HER-2 gene amplification.

Okay, so I am wondering what Perineural Invasion. and "pagetoid"spread are?  I also wonder if it seems that I had both ILC and IDC.  Can someone fill me in on what the e-Cadherin testing means,also the 34BE12 special stain.  It seems that one area had positive reactivity and the other was negative.  Does that have any practical meaning?  Also, is there anything significant in what it says about the pleomorphic variant?  The report itself seems "pieced" together.  Any input you all have is most appreciated.  Overall I feel like it is basic, and good information.

Thank you and Hugs,

Susan

IllinoisNancy

Hi,

Wow, you really got a detailed path report.  Mine wasn't nearly this involved however I see we have some similar characteristics. I am a Pleomorphic ILC and my path said that I had focal areas of lobular carcinoma in situ.  My doctors told me that the cells just look different in my type of cancer and I'm thinking it is the same for you.  I was Grade 2, ER+ and HER2-.  The good news is that I'm doing great and my oncotypedx was very low.  I just went for my 3 year checkup and everything is clear.  I wish you good luck with your treatments and don't get too excited about your detailed path report.  Leave that to the doctors and just follow their instructions.

leaf

Well, I'm certainly not an expert.  (I only have classic LCIS and nothing worse.)

Cadherins are a group of proteins on a cell surface.  They are driven by Calcium ions (hence the Ca), and they adhere cells together (hence the 'adherin'). (Biochemists can have a strange sense of humor.)  They act sort of like velcro.  E-cadherin  is on epithelial cells. http://en.wikipedia.org/wiki/Cadherin

ILC usually doesn't have e-cadherin.  This is thought to influence the way ILC grows - it tends to grow in sheets.  IDC tends to have e-cadherin - it tends to grow in  lumps (the cells adhere together.)

I have LCIS with pagetoid spread to the ducts.  From what I've read I think this means the cells are 'in a row' like soldiers.  I also have seen one poster with 'DCIS with pagetoid spread to the lobules', so I guess it can go both ways.

My impression is that tumors often have various populations of cells in them, so different parts can react differently to some  stains.  An example of this may be one kind of resistance. When you have a resistant cancer, it may kill off part of the cells.  In some resistant tumors, the cells that remain are the cells that have some sort of resistance to the chemo.  Since the sensitive cancer cells were killed off, the resistant ones are left to grow. 

I am no expert on ILC, and I hope someone will correct me if I've made mistakes.  

Gitane

It appears that the invasive component is very minor, good news!  Interesting that the first biopsy labeled it ductal and the others labeled it lobular.

I will tell you what I can.  However, I would very much like you to understand that this information is being shared from someone doing amateurish research,  I'm far from knowing enough to give you good answers.

perineural invasion= I think this means carcinoma cells are seen growing along the edges of nerves.  I don't think it means carcinoma is growing into the nerve fibers, but I don't know. I don't know if this means anything in terms of prognosis or treatment.

e-cadherin testing= e-cad staining is weak or absent frequently in ILC.  Because of this, this stain is often used by pathologists to discriminate between IDC and ILC clusters of cells.  BC with no e-cad staining may grow as individual cells or in an indian file pattern (in single file lines).  e-cad affects cell adhesion.  The prognostic significance of negative e-cad staining is different for IDC than ILC. 

pagetoid spread= cells growing into another structure or surface

34BE12 = As I have read about it, seems to be a stain used in prostate cancer to identify the basal cells.  I don't know what it means in breast cancer.

pleomorphic =  Pleomorphic ILC is a variant of ILC.  The studies on it's prognostic significance are old and underpowered.   My oncologist said pleomorphic ILC responds better to chemo than classical ILC. 

In your case the invasive cancer cells seem to be of intermediate grade.  In ILC this usually comes down to the pleomorphism of the nuclei because ILC never has tubular structures (always gets 3 points for that) and almost always has a low mitotic rate (gets 1 point for that).  If you have small nuclei (gets 1 point) you are low grade ILC.  If you have pleomorphic nuclei (gets 2 or 3 points) you are intermediate grade.  Oncotype DX gives you more information.  For example, IllinoisNancy, above, has an Onco score of 9, while I had an Onco score of 23.  Since you have a small, node negative situation, you may want to ask for an Oncotype test, just to find out more.

Anonymous

Thank you all so much for your help.  I am not stressing out about the report, it is what it is, as they say.  It is just good to have some basic understanding of what it says.  I did have the oncotype test and my score was a 24.  I signed up for the TAILORx clinical trial and was randomized to chemo.  My onc said she would have recomended it with that score any way, because she feels that the pleomorphic variant is more aggressive, and ILC is sneaky.  The good news is that it was caught early, and I had BLM so I've been proactive.  The onc isn't thinking I really have anything to worry about, but she is conservative, and swears she will keep a good eye on me.  You all are an amazing resource, and I really appreciate you taking the time to share your information with me.

Thank you,

Susan