FLORID LCIS

karmicmom

I am 42 and 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.  

My questions are:

1) How long can I sit on florid LCIS without intervention?

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

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

CPP-12-21720, 8/3/2012 ( FROM EXCISIONAL BX, path from mastectomy is below that)
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. 

Anonymous

when I googled "is florid LCIS the same as pleomorphic LCIS?" the responses that came up seem to indicate yes, they mean the same thing. They do say that PLCIS is more aggressive than classic LCIS, but they seem to have a really hard time predicting anything with either or them. so I don't know whether they could really give you any hard and fast answers.  but it sounds like you are in good hands, seeing both an oncologist and a IVF specialist.

Anne 

leaf

Its confusing to me, but I think that florid LCIS is NOT the same as pleomorphic LCIS.  I think that florid LCIS has a different overall growth pattern, and that pleomorphic LCIS has irregular nuclear characteristics (among other things.)

This is from a slideshow from a professor at UCSF in May 2012 about LCIS.  (Sorry the URL is so long.)

  https://docs.google.com/viewer?a=v&amp;q=cache:jxDKPQCB3TUJ:www.ucsfcme.com/2012/slides/MAP1201A/18YiChenWhenIsLCISClinicallySignificant%20.pdf+&amp;hl=en&amp;gl=us&amp;pid=bl&amp;srcid=ADGEEShwSK22V9mrK0rgZYcLb80yyu3kbomxF1VJr7_Qu-mQNcBgwmgkDCf8xODiof8eTeXBuHCYUxua5w20PwCUFnIaz8UdzEV3HjQIBP-Ttvquezt02YHZ_yPfnnPIzOZc7V8aXWlq&amp;sig=AHIEtbQHJTe9hBp7ztJY4dOoBYyDwPf-oA

In it, on page 8, it categorizes LCIS as:

   Classic LCIS
Classic small cell type (type A)
Large cell type (type

LCIS variants
Pleomorphic
Florid or macroacinar
Necrotic
Signet ring cell

The characteristics of each type are described in the slideshow.

It describes both PLCIS and florid LCIS as more aggressive types.  In general, it recommends LCIS variants to be managed like DCIS.

There are other references (which I lost when researching this) that more indirectly suggested florid LCIS was different than pleomorphic LCIS.  I think its confusing, because many entries in Google refer to 'Florid or pleomorphic types of LCIS'.  

Also, at least in the past, different pathology sites have defined LCIS differently.  There is sometimes disagreement between pathologists about LCIS (and other) diagnoses.

Since you have an unusual type of LCIS (along with having found ILC),  with very little information about treatment of the florid LCIS, and are hoping for pregnancy, you may (or may not) want to get a 2nd opinion at a prominent facility.  You may prefer one place over another.  You have a much more unusual breast situation than I did.  You may (or may not) also (if you have not already) want a 2nd opinion about re-reading your slides. (I preferred the oncologist at my local place vs the breast surgeon at the NCI-certified major institution.)  But I'm glad I got a 2nd opinion because I learned from that visit.

karmicmom

Dear Leaf,

   Your response is super-helpful.  It gives me more confidence in my BS since he did talk about excising this type of florid LCIS with necrosis and calcifications.  I will meet with him next week and decide when to go back for clear margins.

 XO,

Karmicmom 

auntiems3

Hi Karmicmom,

I have a link to a recent study done on florid LCIS.  From what I have read it is not considered the same as PLCIS (but nothing would surprise me at this point) but is called a "varient" which mimics DCIS.   www.ncbi.nlm.nih.gov/pubmed/21287281

If this were my path report, my first question to the bc would be "Are the margins clear of ILC?"

This is the part of the path report which sounds like it is causing some concern.

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).

Ask your bs to explain this in better detail.  All of your questions are really good, and I agree with Leaf that it is always a good idea to send those slides out for another opinion from someone who specializes in LCIS and ILC.  Ask your docs who they recommend.  I had mine sent to David Page at Vanderbilt University.  He has been researching ALH and LCIS for over 20 years.

Best regards, Marie

karmicmom

Hi Marie,



Thanks for your reply. This is part of the path report that concerns me:

1.  Florid lobular carcinoma in situ with comedonecrosis and

calcification, present at inferior margins.  



I met with BS today and he said path is reviewing exactly how much of the margin is clear of F LCIS but he is 90% sure that he got all of it. He said he will go back and re-excise when I get my TE exchanged or sooner if I want. At this point, we are waiting for path but I am opting to go back to OR for re-excision sooner rather than later. I really appreciate your recommendation for second opinion. I will ask them to do that.



In love and health,

Karmicmom

rosyFL

OMG, how many different types of LCIS are there? 

leaf

More and more as pathologists look at more samples and classify things differently.  Pathology is a fluid science.

Note: different pathologists can define different diseases differently.  Even if you use strictly the same definition for each diagnosis, different pathologists can classify breast cancers differently.  That's why some patients choose to have their pathology re-read at
 (more) prominent pathology labs if there is a questionable result.  I'm sure pathologists tend to be conservative people and tend to get 2nd opinions if they there is a question.  However, there can be disagreement.  This is mostly only relevant when a different diagnosis leads to a different treatment scheme.

As described in my post above, that May 2012 slideshow opined there were at that time these types:

 Classic LCIS
Classic small cell type (type A)
Large cell type (type

LCIS variants
Pleomorphic
Florid or macroacinar
Necrotic
Signet ring cell

docs.google.com/viewer?a=v&q=c...

rosyFL

leaf, I noticed you put ER+PR- after your dx.  How do you know this?  My pathology report does not mention anything like this any where in the report.  Other than my second opinion (which I requested) on my pathology report which states classic type LCIS, the first pathology report did not even mention classic, just LCIS.

leaf

It was from my pathology report.    Some pathology reports are a lot more detailed than others.  I had my excision re-read at a major institution, and the report from the major institution was 1 sentence at most.  The major institution pathology report did not include the words classic, ER or PR.  My diagnosis only changed from LCIS and cells with features of ALH to LCIS plus ALH.

rosyFL

You would think that there would be a set standard for pathology reports, giving as much detail as possible. 

My second opinion reading was from a major cancer hospital, and they did say "classic".  I also have ADH which both reports mentioned.

Anonymous

rosy--I think "florid" could be another term for pleomorphic, I'm not sure. My pathology report only said LCIS; I think they only differentiate if it is PLCIS, and don't state "classic" if it is LCIS. They were going to test for estrogen receptors with mine, but said the sample was too small, but said most all LCIS is estrogen positive anyway.

Anne

rosyFL

I remember reading that somewhere, about LCIS being mostly estrogen positive, but I really think that they should include this in the pathology reports where lumpectomy has been done.  

Rosy

leaf

They actually only tested my core biopsy (which showed classic LCIS) for ER and PR receptors; they didn't test my excision sample for ER or PR.

According to Dr. Chen's slides, ?they (not sure if there is controversy about this) classifies florid LCIS as different than pleomorphic, though they are both thought to be a more aggressive variant. https://docs.google.com/viewer?a=v&amp;q=cache:jxDKPQCB3TUJ:www.ucsfcme.com/2012/slides/MAP1201A/18YiChenWhenIsLCISClinicallySignificant%20.pdf+&amp;hl=en&amp;gl=us&amp;pid=bl&amp;srcid=ADGEEShwSK22V9mrK0rgZYcLb80yyu3kbomxF1VJr7_Qu-mQNcBgwmgkDCf8xODiof8eTeXBuHCYUxua5w20PwCUFnIaz8UdzEV3HjQIBP-Ttvquezt02YHZ_yPfnnPIzOZc7V8aXWlq&amp;sig=AHIEtbQHJTe9hBp7ztJY4dOoBYyDwPf-oA  (see pages 9-11)

Tarrah

Ok, I posted under dcis, but actually have florid LCIS.  Is a PBMX crazy for stage 0, one side and supspicius lesions on other side that have not been biopsied?  I have implants and actually think they helped to find LCIS.  Don't want chemo., drugs or radiation.  Who does? Am I jumping the gun with a radical procedure.  My Doc has agreed to perform the PBMX.  Any thoughts or advice?  No lymph activity from MRI..........Also, no  second opinion (PS and SO)

loriio

Tarrah,

Glad you posted over here. . As you can see from reading prior posts, there are a lot of knowledgeable ladies ( Leaf and Awb come to mind among others). But there are a lot of unknowns with LCIS. I hadn't heard of Florid LCIS until this recent post. Are you seeing a medical oncologist? I found meeting with one invaluable in making my decision. Also, the nurse navigator at the breast center at my hospital was amazing. Friends and family mean well but unless they've personally confronted this decision, it's hard to understand. Nothing is easy about LCIS. When I was first diagnosed, I described it as no man's land: not malignant but yet mastectomy and tamoxifen are 2 of the recommended treatments. I am sending best wishes your way. I hope you find support for whatever decision you make.

Lori