Pleomorphic LCIS

karmicmom

I'm 42 and was trying to get pregnant until I was diagnosed with LCIS on needle bx in 7/12 and ILC on excisional biopsy in 8/12.  I transferred my care to a different hospital who said there was ILC in the needle bx in 7/12 as well.  I pasted the path report below. I had L mastectomy last week but there is still florid LCIS at the inferior margins but no invasive found and negative nodes.  I pasted the report below. This is mostly great news but now my BS said he will excise it when they do surgery again.  I am planning to do prophylactic right mastectomy later in case I get pregnant and breastfeed.  My oncologist and IVF specialist have been very encouraging about pregnancy not worsening my outcome.  However, it would delay Tamoxifen treatment.

My questions are:

1) How long can I sit on pleomorphic LCIS without intervention, ie Tamoxifen if I try to get pregnant?

2) Should I have the left chest re-excised asap?

 I realize that my health is a priority and if pregnancy (which will not be easy anyway at my age) will be in obstacle in my treatment, then I'm happy to look into adoption and surrogacy.  

 Thank you so much in advance for your advice.  I'd love to hear from others with experience with pleomorphic LCIS.  Love to all of you. 

CPP-12-21720, 8/3/2012 ( FROM EXCISIONAL BX)
A.  Left breast, at 6 o'clock, needle localized excision:
1.  Extensive lobular carcinoma in situ, mixed florid and classic types,
with associated microcalcifications and focal necrosis, present at
excision margins; see comment.
2.  Usual ductal hyperplasia, apocrine metaplasia, focal secretory
change, microcyst formation, and duct ectasia.
3.  Prior biopsy site changes.

B.  Left breast, at 5 o'clock, needle localized excision:
1.  Invasive lobular carcinoma, SBR Grade 2, 1 cm greatest dimension on
glass slides, focally present at inked specimen edge; see comment.
2.  Extensive lobular carcinoma in situ, mixed florid and classic types,
with associated microcalcifications and focal necrosis, present at
excision margins; see comment.
3.  Fibroadenoma.
4.  Usual ductal hyperplasia, apocrine metaplasia, microcyst formation,
and duct ectasia.
5.  Prior biopsy site changes.

COMMENT:  
Thank you for the opportunity to review this case.  I agree with the
original pathologist's diagnosis of invasive lobular carcinoma in
CPP-12-21720; in addition, invasive lobular carcinoma is present in the
biopsy specimen (CPP-12-18972).  All specimens also show extensive
lobular carcinoma in situ (LCIS).

Sections of the left breast core biopsies (CPP-12-18972) show extensive
LCIS, with associated microcalcifications as well as comedonecrosis.  In
addition, the cores containing calcifications (Part A) show an
infiltrative component, with cord-like/single file arrangement of cells
with an associated stromal reaction, consistent with a component of
invasive lobular carcinoma (ILC).  The lobular phenotype is confirmed on
the submitted E-cadherin immunostain, which shows loss of staining in
both the LCIS and ILC.  The presence of ILC is confirmed on the
submitted immunostains for calponin and p63, which show loss of
staining, and thus loss of myoepithelial cells, around the infiltrative
component.  Although much more subtle, a focus of ILC (<1 mm) is also
present in the cores designated as without calcifications (Part .

Given the fragmentation of the left breast excision at 5 o'clock
(CPP-12-21720, Part , the exact size of the tumor and margin status
are difficult to determine with certainty.  In addition, crush and
cautery artifact somewhat limit evaluation of the margins.  The best
estimate of size is 1 cm, based on the single largest dimension on a
slide (slide B12).  The ILC is focally present at the inked and
cauterized specimen edge on slide B11; LCIS is more extensively present
at the inked margins.

No invasive lobular carcinoma is seen in the left breast excision at 6
o'clock (Part A).

Breast Needle Core Biopsy Tumor Synoptic Comment for CPP-12-18972

- Invasive tumor type:  Invasive lobular carcinoma, classic type.
- Invasive tumor size:  0.4 cm single largest linear dimension (slide
A1).
   - Invasive tumor grade (modified Bloom-Richardson):  The grade
noted here is based on the biopsy specimen; the grade is confirmed on
the excisional specimen (see tumor synoptic below).
   - Nuclear grade:  2 points.
   - Mitotic count:  1/10 HPF, 1 point.
   - Glandular/tubular differentiation:  3 points.
   - Total points/grade:  6 points = Grade 2.
- Lymphovascular invasion:  None.
- Ductal carcinoma in situ:  None.
- Microcalcifications:  Present, involving lobular carcinoma in situ.
- Lobular carcinoma in situ:  Present, mixed florid and classic types.

   - Tumor biomarker (ER/PR/HER2) status:  Immunohistochemical stains
for ER and PR were performed on block A1 at the original institution and
are submitted for review.
   - ER:  Positive (2-3+ staining in >90% of tumor cells).
   - PR:  Positive (2+ staining in >90% of tumor cells).

Breast Tumor Synoptic Comment for CPP-12-21720, Part B

- Laterality:  Left.
- Tumor site:
   - Position:  5 o'clock.
- Invasive tumor type:  Invasive lobular carcinoma, classic type.
- Invasive tumor size:  1 cm.
        - Tumor size determined based on largest dimension on the
slide (B12); see comment above.
- Invasive tumor size after neoadjuvant therapy:  Not applicable.
- Invasive tumor grade (modified Scarff-Bloom-Richardson):
   - Nuclear grade:  2 points.
   - Mitotic count:  1 point.
   - Glandular/tubular differentiation:  3 points.
   - Total points:  6 points = Grade 2.
- Lymphatic/vascular invasion:  None.
- Skin/nipple:  No skin/nipple present.
- Skeletal muscle:  No skeletal muscle present.
   - Margins for invasive tumor:  Cauterized tumor cells focally
present at inked specimen edge (slide B11, best appreciated on the
calponin, p63, E-cadherin and AE1/AE3 immunostains; see comment above).

   - Ductal carcinoma in situ (DCIS):  None.
- Microcalcifications:  Present, involving LCIS.

- Lobular carcinoma in situ:  Present, mixed florid and classic types.
   - Non-neoplastic breast:  Fibroadenoma, usual ductal hyperplasia,
apocrine metaplasia, focal secretory change, microcyst formation, duct
ectasia, prior biopsy site changes.

- Lymph node status:  None present.
- AJCC/UICC stage:  pT1bNX.

   - Tumor biomarker (ER/PR/HER2) status:  Immunohistochemical stains
for ER, PR, Ki-67, and HER-2/neu were performed on block B12 at the
original institution and are submitted for review.
   - ER:  Positive (3+ staining in >90% of tumor cells).
   - PR:  Positive (3+ staining in >90% of tumor cells)
        - Ki-67:  18% nuclear labeling index (based on counting of 3
representative high power fields on photomicrographs).
   - HER-2/neu:  Negative (0).

FINAL PATHOLOGIC DIAGNOSIS (from mastectomy)

A.  Left axillary sentinel lymph node #1, biopsy:  No tumor (0/1).

B.  Left axillary sentinel lymph node #2, biopsy:  No tumor (0/1).

C.  Left breast, total skin-sparing mastectomy:  
1.  Florid lobular carcinoma in situ with comedonecrosis and
calcification, present at inferior margins.  
2.  Radial scar with usual ductal hyperplasia.
3.  Surgical site changes.

D.  Left breast anterior margin over tumor, excision:  
1.  No tumor. 
2.  Healing surgical site changes.
E.  Left nipple, excision:  No tumor.

F.  Right breast, wire-localized excisional biopsy:  
1.  No tumor.
2.  Fibroadenomatous changes and pseudoangiomatous hyperplasia.
3.  Cysts and mild usual ductal hyperplasia. 
4.  Collagenous spherulosis. 

 A.  Left breast, with calcifications, needle core biopsy:

1.  Invasive lobular carcinoma; see comment.
2.  Lobular carcinoma in situ, mixed florid and classic types, with
associated microcalcifications and focal necrosis; see comment.
3.  Skin with no significant pathologic abnormality.

B.  Left breast, without calcifications, needle core biopsy:
1.  Small focus of invasive lobular carcinoma; see comment.
2.  Lobular carcinoma in situ.