2d or 3d pathology opinion to rule out microinvasion?

candles1

1st pathologist after 8 gauge vac assisted stereotactic core biopsy: DCIS, grade 3, comedonecrosis, microcalcification, no invasion found in the core sample.

2nd pathologist: concurred with the findings of the 1st pathologist (re: the biopsy sample).

3rd pathologist (after lumpectomy): residual DCIS found around the biopsy site, grade 3, central necrosis, no invasive tumor identified.

Three sentinel nodes negative.

Since margins not cleared to 2mm, planning a mastectomy now. But, should I have another opinion on the final pathology? Seems to me that high grade DCIS with comedonecrosis is more likely to harbor microinvasion, and wouldn't this be important to get absolutely right? Or..has it been sufficiently examined now? Or...is it even that important to know since I'm going to have a mastectomy anyway? The lesion was estimated to be 15mm.

Annette47

If you are having a mastectomy, and have already done a sentinel node biopsy which was negative, then the presence or absence of a micro-invasion would not really change your treatment plan at all (and your outcomes much either), so I personally wouldn't bother. Plus, they will do an examination of the tissue removed via mastectomy as well, so if there is any as yet undetected invasive cancer it would be identified then, but as I said, unless it was larger than a micro-invasion it wouldn’t change your treatment plan at all.

I had a micro-invasion which was identified on the original stereotactic biopsy, and the only difference it made was that I had a sentinel node biopsy. Otherwise my treatment was the same as it would have been for pure DCIS.

MTwoman

candles, I agree with Anette. All 3 opinions previously given were consistent. And as it sounds like you are already planning a MX, having a second opinion on your lumpectomy pathology doesn't seem necessary. If there had been a difference of opinion, or if you weren't already planning MX, then it might be advisable. They will be performing pathology on your breast tissue after MX. If there are any additional findings, there is still time for another opinion or to alter your final treatment plan. Good luck!

BarredOwl

I would note two things for information only.

First, while the presence of microinvasion (T1mi is a Tumor ≤ 1 mm in greatest dimension) does not in general have a large impact on prognosis, in some cases, the presence of microinvasion could alter treatment considerations (although not necessarily the ultimate treatment recommendation). For example, with node-negative (N0), micro-invasive breast cancer (ductal, lobular, mixed or metaplastic) that is HER2-positive, National Comprehensive Cancer Network (NCCN) guidelines (Version 2.2016) include consideration of adjuvant chemotherapy plus trastuzumab (Herceptin) (with a lower level of consensus, Category 2B) (See Charts BINV-5 and BINV-7). Many patients may reasonably decline such treatment after considering their personalized risk / benefit. For more discussion, see this thread:

Forum: Micro-invasive DCIS that is HER2 positive: https://community.breastcancer.org/forum/111

Secondly, a recent 2016 guideline addressed margin sizes in DCIS with breast conserving treatment and whole breast irradiation. The guideline appears to take a case-specific approach to recommending mastectomy with negative margins less than 2 mm:

Morrow (2016): "Society of Surgical Oncology–American Society for Radiation Oncology–American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Ductal Carcinoma In Situ"

Main Page: http://ascopubs.org/doi/abs/10.1200/JCO.2016.68.3573

(pdf version available under PDF tab)

"Results. Negative margins halve the risk of IBTR [ipsilateral (same) breast tumor recurrence] compared with positive margins defined as ink on DCIS. A 2-mm margin minimizes the risk of IBTR compared with smaller negative margins. More widely clear margins do not significantly decrease IBTR compared with 2-mm margins. Negative margins narrower than 2 mm alone are not an indication for mastectomy, and factors known to affect rates of IBTR [ipsilateral (same) breast tumor recurrence] should be considered in determining the need for re-excision.

Conclusion. Use of a 2-mm margin as the standard for an adequate margin in DCIS treated with whole-breast irra- diation is associated with lower rates of IBTR and has the potential to decrease re-excision rates, improve cosmetic outcomes, and decrease health care costs. Clinical judgment should be used in determining the need for further surgery in patients with negative margins narrower than 2 mm."

As some clinical judgment (in light of all relevant considerations) may be involved in some cases of conversion to mastectomy, this may be a possible area where some patients might choose to seek a second opinion (or not). Of course, patient preference is also a consideration.

BarredOwl

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The NCCN guidelines for breast cancer are available for free with registration here:

https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

Shoregirl

In my case, my stereotactic biopsy, breast MRI, and ultrasound ALL indicated Grade 3 DCIS w/microinvasion, but my pathology from BMX showed pure DCIS with no microinvasion. Boy, was I relieved, but the stress of thinking it was worse than it actually was...SMH. I really don't understand how my pathology could go from microinvasive to not microinvasive, but I am thankful!! Medicine isn't perfect. I wish you all the best for a full recovery

BarredOwl

Hi Shoregirl:

Please be sure to obtain complete copies of the pathology reports (not some summary in a patient portal), including all supplements or addenda, for all biopsies and surgeries.

The combined pathology findings from all biopsies and surgeries should be considered together.

If a stereotactic biopsy identified an actual microinvasion (a focus of "T1mi" invasive breast cancer, where Tumor ≤ 1 mm in greatest dimension), then microinvasive disease was established.

pT1mi N0 M0 disease is Stage IA breast cancer (and due to invasion, cannot be Stage 0):

AJCC (7th Edition) Staging Summary: https://cancerstaging.org/references-tools/quickreferences/Documents/BreastMedium.pdf

The mere absence of an additional area of invasion in the tissues removed in a subequent surgery does NOT negate a prior finding of microinvasion in the biopsy tissue sample.

If for some reason the biopsy slides were reviewed again, and there was a change in opinion about the prior finding of microinvasion, this must be expressly addressed in writing by the pathologist in a revised written report or addendum, and you should obtain a copy. In the absence of an express statement, you cannot just assume the microinvasion did not exist. Further inquiry is required. Please discuss how the combined pathology findings from biopsy and surgery should be viewed with your team. If there is any question regarding the finding of microinvasion, your surgeon or medical oncologist should work with the pathologist to obtain clarification.

Because invasive disease can have different features from the associated DCIS, under NCCN guidelines for breast cancer (Version 2.2016), the microinvasive focus should be separately tested for ER, PR, and HER2 status, if possible. If such testing has not been performed, please request such testing or a reasoned explanation of why such testing is not feasible.

I would be inclined to request a referral to a medical oncologist to inquire specifically about: the implications of the biopsy findings to your overall diagnosis; the ER, PR, and HER2 status of the microinvasion; how the microinvasion may influence your recurrence risk profile; and recommended treatment plan in light of the features of both the DCIS and the microinvasion.

BarredOwl

Shoregirl

Hi BarredOwl,

Thank you for the message I do have original path reports, I don't like those online portals much. I looked back at everything, and I misspoke a bit. The stereotactic biopsy path report says

MICROSCOPIC DIAGNOSIS;

A. Right breast, 9:00, indeterminate new calcifications, core biopsies: DUCTAL CARCINOMA IN SITU, HIGH-GRADE, W/NECROSIS & CALCS, SOLID/CRIBIFORM TYPE. FOCI OF MICRO-INVASION ARE IDENTIFIED. IMMUNOSTAIN RESULTS: ER: NEGATIVE (0%;ABSENT) PR: NEGATIVE (0% ABSENT). THE CONTROL STAINS APPROPRIATELY.

B. Right breast, 9:00, no calcifications, core biopsies: FOCI OF DUCTAL CARCINOMA IN SITU, HIGH-GRADE, CRIBRIFORM TYPE, W/NECROSIS, MAXIMUM ON SLIDE EXTENT EQUALS 10MM. (BIRADS 6 - known biopsy proven malignancy was noted on the final imaging report.)

MRI FINDINGS: There is a moderate amount of fibroglandular tissue w/minimal background enhancement.

Right breast: in the 12 o'clock position, ......1.8 x 1.9 x 1.8 cm area of irregular masslike enhancement w/multiple foci of lobular extension into the surrounding breast tissue. (I took this to mean micro - invasion).

In the lateral right breast at the 8 to 9 o'clock position, there is a 2.1 x 1.5 cm area of branching enhancement. Biopsy clip in posterior margin of this abnormality. ......Several foci of linear extension inferiorly which are less than a centimeter in length. And posterior to both of these processes, just below the nipple in the 6 - 6:30 position of right breast, ......there is a 5 mm focus of linear enhancement extending for approx 1 cm in the craniocaudead dimension. BI-RADS code 5. Overall, the extent of disease spans a distance of greater than 5 cm.

IMPRESSION:

1. .....mass 12:00 position rt breast highly suspicious for malignancy. 2nd look ultrasound w/intent to biopsy is recommended.

2. ......2.1 cm area of branching enhancement in the lateral rt breast corresponding to the biopsied DCIS.

3.........3rd smaller area of enhancement just inferior to the nipple line at the 6-6:30 position of rt breast, middle depth concerning for an area of DCIS.

Note is made that these 3 areas of fisease span a distance of greater than 5 cm in the prone breast.

4. .....Possible intramammary node in the upper outer left breast for which second look ultrasound is recommended. If a node is not found, a six-month follow-up MRI is recommended to evaluate for stability.

BIRADS CATEGORY 5 - highly suspicious for malignancy. Biopsy should be performed.

The ultrasound was done to check both axillary nodes, left breast determined to be ok, but US tech and nurse nav both made me feel like I had a lot going on in that rt breast so I made the decision to go for BMX.

My Final DX from BMX says:

1. HIGH-GRADE DUCT CARCINOMA IN SITU W/COMEDO NECROSIS AND CALCIFICATIONS SHOWING NUCLEAR GRADE 3/3 AND SPANNING A MICROSCOPIC DISTANCE OF 7MM AT THE 9:00 LOCATION. STROMAL INVASION IS NOT IDENTIFIED. THE LESION IS LOCATED CLOSELY TO THE PROSTHETIC CAPSULE.

2. A SECOND LESION IN A RANDOM SECTION OF THE UPPER OUTER QUADRANT CONSISTS OF INTERMEDIATE GRADE DCIS OF THE SOLID AND CRIBRIFORM TYPES SHOWING NUCLEAR GRADE 2/3, EXTENSION INTO TERMINAL LOBULES AND SPANS A DISTANCE OF 8MM. STROMAL INVASION IS NOT IDENTIFIED.

3. THE NIPPLE SKIN, MARGINS OF RESECTION AND RANDOM SECTIONS OF THE REMAINING QUADRANTS ARE FREE OF TUMOR. 2 SENTINAL NODES WERE TAKEN, BOTH NEGATIVE.

CANCER SUMMARY: TOTAL MASTECTOMY, MACROSCOPIC: Neoadjuvant therapy: no, Multifocal: yes, Multicentric: no

MICROSCOPIC: Size of invasive component: n/a, Size of DCIS: mm 7 and 8, Histologoic grade: n/a, Tubule formation : n/a, Nuclear pleomorphism: 3 and 2, Mitotic count: 2 and 1, Nottingham score: n/a, Venous/lymphatic invasion: no. Closest margin size mm: greater than 10.

Markers: ER: percent staining: 0, interpretation: negative. PR: percent staining 0, interpretation: negative. Her2: n/a, Her2 FISH: n/a

Ki-67: percent staining: n/a

Summary TNM: t: pTis (dcis) pN: pNx Summary stage: 0

Nowhere in the Stereotactic biopsy path report does it state "a focus of "T1mi" invasive breast cancer, where Tumor ≤ 1 mm in greatest dimension), then microinvasive disease was established" as you mentioned to me, but it DID say "FOCI OF MICRO-INVASION ARE IDENTIFIED."

I am taking what you said very seriously, and WILL ask for the stereotactic biopsy to be re-examined. Thank you so much for your concern, and for bringing all this to my attention!! I will close by saying that I DID have a bilatateral breast reduction surgery back in 1993, I don't know if that skewed any of the findings due to scar tissue.

Warm regards,

Shoregirl

BarredOwl

Hi Shoregirl:

Thank you for your message and additional information. The information on the MRI is not clearly indicative of invasion. However, the pathology report for the biopsy does indicate that invasion was observed.

(1) Biopsy

The biopsy identified an area of DCIS (high grade) and "FOCI OF MICRO-INVASION ARE IDENTIFIED." The word "foci" is plural, meaning that more than one focus of micro-invasion was identified.

Invasion is typically determined using immuno-histochemical ("IHC") stains, which reveal that malignant cells have broken through the outer myoepithelial layer of cells surrounding the duct and have invaded the surrounding breast tissue.

Under AJCC staging criteria and definitions (7th edition), a single "micro-invasion" is by definition an invasive focus that is less than or equal to 1 mm in greatest dimension.

Although sometimes referred to as "DCIS with micro-invasion" ("DCIS-MI"), under AJCC staging criteria, the presence of one or more micro-invasion(s) is considered to be "T1mi" disease (i.e., invasive breast cancer and not Stage 0 breast cancer).

ER and PR status was determined (ER- PR-), but it is not clear what was tested (i.e., the DCIS and/or one or more of the microinvasions?). This would be another question for your team.

As I mentioned above, under clinical consensus guidelines, when feasible, micro-invasion should be tested for ER, PR and HER2 status.

(2) Surgical Pathology

The surgical samples contained two areas of DCIS (one 7 mm (high grade) and one 8 mm (intermediate grade). No additional areas of invasion of the breast stromal tissue surrounding the ducts were identified. This is indicated by: "STROMAL INVASION IS NOT IDENTIFIED." This describes what was seen in the surgically removed tissue, and does not negate what was seen in the biopsy tissue.

ER and PR status was determined (ER- PR-), but it is not clear whether both areas of DCIS were tested or only one area. This would be another question for your team.

The more common situation is that the first evidence of invasion is found in the more extensive surgical samples. Please follow up with your team as suggested in my prior post to ensure that they have not lost sight of the biopsy findings in this less common situation.

At some point, you may wish to consider seeking a second opinion review of all imaging and pathology results by an independent institution. Copies of all imaging (mammograms, MRIs, ultrasounds) and actual pathology slides, along with all associated written reports, are provided to the second institution for review by a team with the relevant expertise (e.g., Radiologist, Pathologist). If of interest and feasible (e.g., in network), many look for an NCI-designated Cancer Center for this purpose:

https://www.cancer.gov/research/nci-role/cancer-centers/find

Best,

BarredOwl