Micro-Invasion too small to test for ER/PR/HER2

swearp

Thanks once again for reading my post, I am already getting great deal of support from this site. 

My pathology report says within 4.5 CM of DCIS they found multi foci micro-invasion all of which is less than 1 mm (at least 5 places). Report also said sample too small to test ER/PR/HER2 but they will attempt anyways. 

Anyone out here has similar issues ?

I already have one thread under DCIS but though of reposting on specific forum. My DCIS post is:

http://community.breastcancer.org/forum/68/topic/801590?page=1#post_3512225

swearp

I just found out that my DCIS is weakly positive for ER/PR and Micro-Invasion is HER2 positive by FISH with ration of 3.0 (> 2.2 is positive). 

Anyone with the similar DX?

Any thoughts on this?

cher1

I was diagnosed initially with DCIS, then after another lumpectomy to get larger margins, I was diag with micro invasive.  My cancer was 1.3 cm.  I don't racall the number of micro invasives.  I am ER/PR positive and was told that I probably am HR2 Pos although they did not test for that.  My sister who was diagnosed a month earlier than I, was 1.5cm IDC ER/PR/HR2 pos.  She received infusions for HER2, along with chemo and rad.    I am concerned that I will not be treated for HER2 but don't wish for the treatment either.  It just presents another worry.

Beesie

If the microinvasion was too small to be tested, then it probably was only 1mm in size or smaller.  Technically anything larger than 1mm isn't considered to be a microinvasion.  The DCIS portion of the lesion isn't relevant.... DCIS is often HER2+ and there is no difference in the treatment nor is there any clear understanding as to whether HER2+ DCIS is any more aggressive than HER2- DCIS.

With an invasive area that is only 1mm in size or smaller, it would be extremely unusual (virtually unheard of) for you to be prescribed Herceptin.  Generally the treatment for those of us with true microinvasions (I had one too, and no, it was not HER2 tested either) is the same as the treatment for those who have pure DCIS.   Keep in mind that if your sister had a 1.5cm invasive cancer and you had a 1mm invasive cancer, it means that your sister's cancer was 1500% larger than yours.  So even if your cancer was equally aggressive (i.e. if you both had HER2+ cancers), your sister had 1500% more invasive cancer cells that could wreck havoc.

cher1

Hi Beesie,

Sounds logical. I think my doc tried telling me that but instead just kept saying it was small which really didn't help much.  All I could think was, small or large, micro invasive is micro invasive...it's gone through the wall. Sometimes our worries get the better of us.  Thanks

denilynne

Hi Cher,

You sound like me. I absolutely MUST know all the details, I just can't help it! If no one tells me, I go on the web to find my answer and usually end up scaring myself silly! Like you, I have found this site particularly helpful.

When someone says, micro invasion, to me, that's INVASIVE, no matter if it's micro or macro! Scary, scary words!

Denise

Pinckney Mi

cher1

Hi Denise,

Nice to hear from you.  Yep...to help alleviate the worries, we need all the info we can get...hopefully from our doctors.

Beesie

The terminology around microinvasive DCIS can be very confusing. 

First, from a staging perspective, it's called DCIS-Mi.  So you have the "DCIS" part, which leads many women to believe that it's really just a type of DCIS and it's Stage 0, but then you have the "Mi", which is "micro-invasion", i.e. a small (micro) invasion. And yes, a micro-invasion is invasive.  That's why DCIS-Mi is Stage I.  And that's why it does require that the nodes be checked, whereas with pure DCIS, it's not necessary to do any SNB. 

So is DCIS-Mi more like DCIS or it is more like IDC? 

Everything I've read suggests that the prognosis is closer to DCIS.  Or I suppose it's most accurate to say that the prognosis fits very snuggly in that tiny space in-between DCIS and Stage IA with a T1a tumor (i.e. a tumor that is just a smidgen larger than a microinvasion, and a diagnosis that also has an extremely favorable prognosis).

This article explains DCIS-Mi quite well: 

Microinvasive carcinoma of the breast  (micro-invasive DCIS)   Their conclusion: "In terms of management and followup, it is felt that microinvasive breast carcinoma behaves in a manner more like DCIS than invasive ductal carcinoma."

Then there's this recent study:  Ductal carcinoma in situ with microinvasion: prognostic implications, long-term outcomes, and role of axillary evaluation which concludes "Our data imply that the natural history of DCISM closely resembles that of DCIS, with a low incidence of local-regional and distant failures"

And there's this older study:  Mammary ductal carcinoma in situ with microinvasion  which concludes:"The cases of microinvasive carcinoma examined in this study, as defined above, were not associated with axillary lymph node metastases and appeared to be associated with an excellent prognosis."

Neither of these studies even looked at HER2 status (understandable, since the relevance of HER2 status to invasive cancer has been an evolving understanding over the past ten years and at this point we don't yet know the relevance of HER2 status to DCIS) so we can assume that the approx. 1/3 of women who had HER2+ microinvasions were included in these very positive results. 

Some information to help alleviate the worries, I hope!

apenelope

This is super helpful, Beesie! Do you know if the prognosis is the same even if the mi was in the lymph nodes?

With me they found scattered foci of microinvasion (<.01cm) in a whole lotta DCIS (8.5cm) and four (out of five) LN contained isolated tumor cell clusters (<.02cm)- so tiny, clinically, I'm LN negative with no markers for the invasives (Stage 1a).

I'm mostly worried about the wide range of responses I've gotten from doctors concerning treatment.

First, my breast surgeon said, "personally, I'd go for chemo". The next week they take my case in to a board meeting and tell me they recommend I do nothing (because of my age, I'm 27, they say the risks of all treatments outweigh the benefits). Two weeks later, I meet with the head onco (this person was at that meeting too) and I'm told to go on Tamoxifen. I then met with two other doctors at different institutions that told me to go on Tamoxifen but for different reasons. The first told me to do it because although my risk for recurrence is low, 2%, I don't want to regret not doing it if it does come back. The second told me I had to go on it because I my risk was 30-40%, saying it's in my LN, so they're positive since we know it's there.

I don't know how other people feel about it, but a girlfriend of mine also with breast cancer said "Tamoxifen isn't a Flintstone vitamin" and that's how I feel about pharmaceuticals in general. If I'm real with myself, I don't want to take it and have been doing everything I can to delay starting it. I'd feel more confident about not taking it if my risk really is low, but 30-40% scares me. Do those numbers seem right?

Beesie

apenelope, I'm afraid I can't offer much advice or any clarity on your situation. Your situation is just so unusual.

When someone with pure DCIS has ITC in a node, the staging is DCIS Stage 0 and the assumption is that the cancer cells were moved to the node accidentally by a surgical instrument while the node was being removed for the SNB. So in that case, the treatment is the same as if the diagnosis was pure DCIS.

When someone has one or two microinvasions that have not affected the nodes, the staging is DCIS-Mi Stage IA. There is a lot of evidence to suggest that the prognosis is close to what it is for pure DCIS, so here again, the treatment generally is the same as if the diagnosis was pure DCIS.

This changes however when someone who has one or two microinvasions but is also found to have micromets (a nodal invasion that's a bit larger than ITC). That is staged as IDC Stage IB and the treatment is the same as it would be for someone with a very early stage invasive cancer.

Then there is your situation, where you have several very tiny microinvasions and several nodes with ITC. Officially, as you say, your stage is Stage IA - stage I because of the microinvasions, and the "A" because ITC are considered node negative. But with several nodes with ITC, is it still most likely that the ITC landed in the nodes because of a surgical instrument? Or is it more likely that the ITC got into the nodes on their own? And if such tiny microinvasions could lead to several nodes having ITC, does that mean that your invasive cancer is particularly prone to travel? It's impossible to know. Maybe the ITC were accidents and your risk really is just about 2%. Or maybe the ITC came from those microinvasions, in which case your risk might be considerably higher (I have no idea if 30% or 40% is accurate but that seems high to me). Your type of situation is so rare that I can see why it has your doctors confused and why you are getting so many different opinions.

Normally after a BMX for DCIS or even DCIS-Mi, Tamoxifen wouldn't be prescribed. But normally after a BMX for a larger invasive cancer (often even just a T1a tumor and certainly whenever there is nodal involvement), Tamoxifen would be prescribed. You fall right in the middle. The only advice I can offer is something that is often suggested on this board. What about trying Tamoxifen? Not everyone suffers the same side effects and some women tolerate it very well. If you find that you do, you might be happy to continue to take it. But if you find that you are having a lot of problems, then you can reassess whether you want to continue.

Blessings2011

After seven different biopsies and procedures, I was dx'd with Multifocal DCIS (two areas, the largest of which was .6 cm.

Within that area of DCIS, I had two areas of IDC : one was half a millimeter, and the other was one and a half millimeters. Both IDC samples were sent off for IHC testing, revealing ER/PR+ and Her/2/Neu-.

No one ever told me the samples were too small to test; nor did any of my biopsy reports refer to them as "micro invasions".... and even stranger, no evidence of the IDC was found in my final path report.

Beesie - thank you for those links - very informative, and very encouraging!

Annette47

I was never told the size of my micro-invasion, just that it was a micro-invasion and that it was too small to test.

apenelope

Thank you very much, Beesie. The way you spelled it out so clearly is tremendously helpful in helping me make a decision. I appreciate you taking the time to do so!

apenelope

Also, I came across a study that's a bit old but the results are interesting. It might be helpful for others who find themselves in a similar situation (though unlikely).

They found that "Metastasis free and overall survival probabilities were significantly different between three groups in the following order from best to worst prognosis: 1) the group comprising DCIS and DCIS-MI type 1, 2) the DCIS-MI type 2 group, and 3) the IDC-DCIS group." The difference between Type 1 and Type 2 was whether the cells were isolated or in clusters (respectively). "The only important point is to make the distinction between invasive single tumor cells and invasive cell clusters. The presence of these clusters increases the metastasis risk, and this risk increases as their number increases."

Survival rates are as follows:

"Metastasis free probability and OSP were not significantly different in DCIS and DCIS-MI type 1 (at 10 years, respectively, 98% and 97% for MFP and 96.5% and 96.3% for OSP). A significant difference was found for MFP between DCIS and DCIS-MI type 2 (98% vs. 91%; P < 10⁻⁴) and between DCIS-MI type 2 and IDC-DCIS (91% vs. 79%; P = 2 × 10⁻³). For OSP, there was a significant difference between DCIS and the DCIS-MI type 2 (96.5% vs. 88.4%; P < 10⁻⁴), and between the DCIS-MI type 2 and the IDC-DCIS (88.4% vs. 78.5%; P = 3 × 10⁻²)."

According to the distinctions made in this article, my risk is probably closer to 10%.

Here's the citation:

de Mascarel, I., MacGrogan, G., Mathoulin-Pélissier, S., Soubeyran, I., Picot, V. and Coindre, J.-M. (2002), Breast ductal carcinoma in situ with microinvasion. Cancer, 94: 2134–2142. doi: 10.1002/cncr.10451

I have access to most journals so if you can't access it and you'd like a pdf just PM me.

Beesie

apenelope, thanks for the information about that study. I recall reading it years ago, and I probably have it bookmarked somewhere (among my hundreds of breast cancer bookmarks!), but I'd forgotten about it. The type 1 vs. type 2 DCIS-Mi distinction that these researchers make is quite interesting, and very logical. It just makes sense to me that there will be lower risk associated with single invasive tumor cells vs. invasive cell clusters. And it makes sense that if there are more clusters, the risk will be higher.

I have always found it strange that from a staging and treatment standpoint, DCIS-Mi is generally considered the same whether there is one microinvasion or many. The one situation where I've noticed that there sometimes are treatment differences is with HER2+ microinvasions. If there is just one microinvasion, or maybe just a couple, Herceptin and chemo aren't considered. But I have seen situations where individuals present with multiple microinvasions, and therefore technically have a Stage IA, T1mic diagnosis, and yet Herceptin and chemo are recommended, despite treatment guidelines that suggest that these treatments only kick with when the tumor size is T1b or greater.

apenelope

i think it's strange too. this information was just what i needed to help me feel like i know my actual risk, and push me to give tamoxifen a try. thank you for all of your help!

Beesie

You're welcome!

MEJ1234

I was diagnosed with IDC in 6-2013.   On my mammogram  April 2013 They saw a spot on the left breast and ordered a MRI.  It turned out that the spot was o.k., but they found a spot on the right breast that had not show up on the mammogram.  After having a needle core biopsy I was told I had invasive ductal carcinoma.  I had a partial mastectomy in June 2013.  I was told it was not ER or PR.  I was stage one.  They wanted to test it for Her2 but there was not enough pathology remaking to do that.  So, I do not know what kind of breast cancer it was.  It was small enough that my oncologist said I would not need chemo.  I did have to do 35 sessions of radiation.   4-5 months later I am still sore to the touch, and my ribs are sore, but I am thankful I did not need to do chemo, and it was caught early on.  I am somewhat concerned about maybe being HER2.  My mom died of cancer at 51.  We were not told it was breast cancer and the time has past so many years ago, there are no records to review.  I do have 2 sister's that did have breast cancer.  One at 39 yrs old died.  The other sister is a cancer survivor of 13 years.  Thank God.  Both of their cancers were HER2.   I guess what I am concerned about is there more I should be doing?   I am sorry I have been pretty long winded, just looking for other opinions.  I am 65 yrs old.  

MEJ1234

I was diagnosed with IDC in 6-2013.   On my mammogram  April 2013 They saw a spot on the left breast and ordered a MRI.  It turned out that the spot was o.k., but they found a spot on the right breast that had not show up on the mammogram.  After having a needle core biopsy I was told I had invasive ductal carcinoma.  I had a partial mastectomy in June 2013.  I was told it was not ER or PR.  I was stage one.  They wanted to test it for Her2 but there was not enough pathology remaking to do that.  So, I do not know what kind of breast cancer it was.  It was small enough that my oncologist said I would not need chemo.  I did have to do 35 sessions of radiation.   4-5 months later I am still sore to the touch, and my ribs are sore, but I am thankful I did not need to do chemo, and it was caught early on.  I am somewhat concerned about maybe being HER2.  My mom died of cancer at 51.  We were not told it was breast cancer and the time has past so many years ago, there are no records to review.  I do have 2 sister's that did have breast cancer.  One at 39 yrs old died.  The other sister is a cancer survivor of 13 years.  Thank God.  Both of their cancers were HER2.   I guess what I am concerned about is there more I should be doing?   I am sorry I have been pretty long winded, just looking for other opinions.  I am 65 yrs old.  

Rlsteadman

MEJ- I also had IDC mine was only 1.2x 1.0 mm.  It was HER2 positive. Saw 2 medical oncologist who said it was to small to do chemo or Herceptin.  1 MO said I could do chemo and Herceptin but thought it would be less than a 5% chance in making a difference. It scares me but I will just hope for the best and pray It doesn't return. I don't have any family members who have had breast cancer. That would make me even more nervous. You are not alone in trying to figure out what to do with these small cancers.