confused on path report diagnosis and next step?

neenie311

The path report reads:

Left breast mass, core needle biopsy: Invasive ductal carcinoma with associated calcifications 1.1 cm. Ductal carcinoma in situ, cribriform type, intermediate grade, with calcifications and focal comedonecrosis. ER+ PR+ HER2 -

First off I dont now what any of this means. My DO just said it was cancer but it was really dcis (invasive?) he wants to send me to a general surgeon for lumpectomy then to an oncologist? I feel uneasy about going in for a lumpectomy before I even see an oncologist. Is that a normal protocol? I feel like I have had a lot of research in on my own as most of the professional I have been working with so far have been evasive and passive...for example, I found the lump and after several months requested the mammo...never seen nor talked to a radiologist until the day of my biopsy and even he told me not to worry four out of five come back b9 (I was birad5) and till this day I have not had one person give me a physical exam on my breasts at all. My DO said the lumpectomy would take out the spots with a margin and then a couple of nodes that the oncologist would want the path back from that anyway. I dont know what to think and there is so much info I am feeling overwhelmed. Does any one have any input on what this path is saying and if going for a lumpectomy prior to seeing an oncologist is a normal route? Thanks sorry to ramble but I was just given the news today and feeling confused.

marie5890

Neenie,

This is the IDC forum link that will also be helpful for you.

Sounds like your DO doesn't know much about BC. Tell them you want to see a breast surgeon. Having the lumpectomy prior to oncologist is ok, as the more information the oncologist has, the better they can advise you

Numb

Your report looks to me like you could have 2 very small tumours, one invasive and one insitu but I am not clear on that from the way it is worded. Having the lumpectomy immediately is the best course and your Oncologist will deal with any treatment you might need after that, e.g. chemo or radiation and hormonal treatment. Best of luck with all of this and don't worry you have been caught early and your tumour is small. I had a lumpectomy before I ever saw my Oncologist too.

marie5890

Here is the main site of BCO that will help you understand your pathology report.

You have Grade 2, cribriform type, IDC and DCIS with focal areas of comedonecrosis

It's small, 1.1 cm

ChiSandy

I am surprised you never had a physical breast exam—even my gyne and medical oncologist do one every time they see me. See a breast cancer surgeon (not a general surgeon) first. Preferably at a decent cancer and/or breast health center. You have both invasive (IDC) and in situ (DCIS) breast cancer. The DCIS is “cribiform” (means the pattern in the ducts looks like Swiss cheese), the words “intermediate grade" and the “focal comedo necrosis” (a very few isolated dead cancer cells that tend to look like blackheads) suggest the DCIS is at least Grade 2 (but the presence of comedo necrosis often accompanies Grade 3 DCIS).

But with a mixed diagnosis, it’s always the attributes of the invasive cancer that determine stage and treatment. And judging from the fact that they didn’t give dimensions of the DCIS (just the IDC) and that the IDC is only 1.1 cm tells me that the DCIS is inside the IDC. DCIS and IDC are not only different in behavior. (DCIS stays put, IDC breaks through the duct) but in cellular composition—you can have IDC without associated DCIS, even though the IDC started in the duct and then broke out and invaded the breast tissue. DCIS becomes invasive only if it mutates, but because there’s no way to predict that, it’s always removed). If the DCIS is the primary (or sole) tumor it’s often far larger. That your doctor is recommending a lumpectomy is probably because of the tumor’s relatively small (just barely t1c, and Stage I) size, relative non-aggressiveness and maybe its location. Where in your breast is it located? Did the report mention the grade of the IDC, not just that of the DCIS?

What your doctor tried to explain to you is how a lumpectomy and sentinel node biopsy will be done. They always take a margin of what appears to be healthy tissue surrounding the tumor, to try and ensure they got it all. Sometimes a re-excision is necessary if there are microscopic tumor cells too far out in the margin, but that doesn’t necessarily mean it’s more aggressive, just that those cells were not visible to your surgeon. It’s not outside the standard of care and it’s not uncommon with other tumors (e.g., when my derm did a shave biopsy of a mole suspicious for melanoma, she couldn’t get clean margins had to “re-excise” by doing a punch biopsy; turned out atypical but benign).

Back in the day, they used to take many or even all the lymph nodes from the armpit, whether you were getting a lumpectomy and mastectomy. They eventually learned that in the vast majority of cases, that was unnecessary. So what they do now is called a sentinel node biopsy. They remove and examine the closest nodes to the tumor from which lymph fluid would drain—if they do not have cancer cells in them, then it means the cancer hasn’t spread. If they do, they remove all the nodes that have them. They find the “sentinel nodes” to remove and examine by injecting them with a blue dye (to make them visible to the naked eye), a radioactive isotope (so they “light up” on an x-ray) or both. Usually, there’s more than one sentinel node, and often there are non-sentinel nodes attached or adjacent to them and can’t be left in place because there’d be nothing to anchor them to. Whether any of those nodes are positive for cancer cells will determine whether you’re Stage IA (negative) or 1B.

The tumor size from the core needle biopsy might turn out to be bigger or sometimes smaller at surgery. That doesn’t mean it grew, only that imaging is less exact than surgery.

Your breast surgeon will lay out your surgical options and the pros and cons for each. Most women with that small an IDC tumor choose lumpectomy with radiation (if it’s located “conveniently,” as mine was); but you also have the option of a unilateral (just the tumor breast) or bilateral (both breasts) mastectomy. Every woman has personal reasons for their choice, and though (s)he will advocate a particular surgical option, a good breast cancer surgeon will honor your preference provided you are fully informed about the pros and cons.

That’s the reason I suggest a breast cancer surgeon—whereas a general surgeon performs perhaps one breast cancer surgery per week, an experienced breast surgeon will do several per day at least a couple of days a week and therefore will have several hundred under his or her belt. They also perform several different breast cancer surgeries because they are proficient in them, whereas a general surgeon may know only one or two. You want someone as experienced as possible, whether you go for lumpectomy, mastectomy or bilateral mastectomy.

ChiSandy

Oh, and 80% of biopsies of BIRADS 4 (“suspicious for malignancy”) tumors turn out to be benign, but BIRADS 5 means “highly suspicious for malignancy.” And even with BIRADS 4, there are subdesignations a, b, and c, with ascending odds of malignancy. Your doctor was trying to keep you from worrying, but should have explained the actual odds.

neenie311

Thank you for the links Marie and Chisandy that was just a wealth of information for me thank you so much. Feeling better about moving forward. I will probably call my doc tomorrow and ask him to refer me to a breast surgeon rather than general surgeon if only to give me the most confidence in this all. I appreciate that you took the time to be so thorough with your response and your time is appreciated, this board is very lucky to have all of you!!