Pathology Meltdown

Veeder14

I had my follow up with the surgeon from the 1/26 lumpectomy today. The Pathology report indicated that in addition to lobular cancer I also had DCIS which is where it probably started. I don't know much about this except I think he said the DCIS was a more aggressive cancer. Final size 8mm not 5mm.

7 lymph nodes were taken out and all are clear, there are clear margins around where the tumor was which is good news. The margins were 1mm, is that standard? However, originally the surgeon said I could probably get away without doing radiation but today he made a referral. I think it's probably standard procedure after lumpectomy but I was expecting him to say I didn't need it.

I just can't get my head around doing radiation with all the risks, and making existing back/neck problems way worse. The surgery and all the diagnostic tests have stressed my back/neck out to the max. Plus, diagnostics and surgery for melanoma that overlaps during the past year with this breast cancer.

I just need a break from all this medical stuff, it's just been constant for the past 14 months. I will go to the radiation consult and see what the options are. How to make a decision I don't know.

wallycat

Deep breath. So sorry you are here.

DCIS is not a precursor for lobular cancer....it may lead to IDC, but nothing in science can determine which are aggressive and which will just sit there and do nothing till you die of something else. Did they grade the DCIS for you?

Most docs recommend rads if you opt for a lumpectomy. It is the standard of care. You can certainly discuss this and voice your concerns (as I did; I opted for mastectomy to avoid rads but even some gals with mastectomy may require rads).

It used to be 2mm for clean margins, but I believe that has changed. Mine was barely 1mm because otherwise it would have hit my chest wall. My surgeon was confident with that.

Best to you.

Veeder14

Thanks for your reply Wallycat. I can't tell if the DCIS is graded as the report says overall Grade 1 and DCIS high grade-no number. Combined Histologic Score 3 + 1 + 1. Histologic Grade for Lobular: Glandular Differentiation Score 3. Pathologic Stage: pT1b and pNO. I was so exhausted, stressed, etc., I didn't get the details explained well.

BarredOwl

Hi Veeder14:

In my layperson's understanding (which could be wrong), unless you were told you have Mixed invasive histology, from the information you provided above, you do not appear to have "Mixed" type breast cancer.

The term "Mixed" ordinarily refers to a type of invasive breast cancer that is of "Mixed" INVASIVE histology.

In contrast, you have an invasive cancer and a non-invasive cancer:

- (a) Invasive Lobular Carcinoma ("ILC", INVASIVE)

- (b) Ductal Carcinoma in Situ ("DCIS", NON-INVASIVE).

So, your invasive hisology is not "mixed" but appears to be "lobular".

You also have some non-invasive disease (DCIS) present.

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Background Information re Grading Systems:

Please note that different grading systems are used to grade invasive breast cancers and to grade DCIS.

(a) Grading Systems for INVASIVE Breast Cancer: There are a variety of methods in use to assign grade for invasive breast cancers. Overall grade can be: Low (grade 1); Intermediate (grade 2); or High (grade 3).

One commonly used system is the Nottingham Histologic Score (Elston grade), which considers three main histologic features of invasive cancer, independently assigns a sub-score for each feature, and then combines the three sub-scores to assign an "Overall Grade". Here is a description of that system from Johns Hopkins:

Nottingham Histologic Score (Elston grade): http://pathology.jhu.edu/breast/grade.php

(b) Grading Systems for NON-INVASIVE DCIS: There are a variety of methods in use to assign grade for DCIS, which is a "non-invasive" condition, meaning the tumor cells are confined inside the duct. Grade can be: Low (grade 1); Intermediate (grade 2); or High (grade 3).

Per a 2013 review article by Bane: "There are three commonly referenced grading schemes for DCIS, all of which employ the assessment of nuclear grade and presence/type of necrosis with some additionally utilising cellular polarity to ascribe an overall grade [9-11]. No one system has been endorsed; however, a consensus conference and the College of American Pathologists recommend that a pathology report should include a description of nuclear grade, presence and type of necrosis, and the architectural patterns present [8,12]."

"Architectural pattern" refers to the terminology used to describe the appearance of cells within the ducts or how full they are with DCIS (e.g., solid, cribiform, papillary).

For a summary of one example of a DCIS grading system, see this Stanford outline here.

===> You can (and should) obtain copies of the complete pathology reports from all surgeries and biopsies for your review and records. The reports may refer to the name(s) of the grading system(s) or provide additional detail.

Your Description:

Re the DCIS: "I can't tell if the DCIS is graded as the report says overall Grade 1 and DCIS high grade-no number."

The overall Grade 1 appears to the refer to the grade of the ILC. Please confirm it with your team.

Per your description, the DCIS is "high grade", which is the highest of three possible grades (Low (grade 1); Intermediate (grade 2); or High (grade 3)). Please confirm it with your team.

Regardless of grade, DCIS is a "non-invasive" condition (confined to the inside of the ducts).

=====> Please check your pathology report for information regarding the extent of the DCIS, its ER and PR status, and the size of the surgical margins relative to the DCIS, which should all be separatley reported from the features of the ILC.

Re the ILC: "[O]verall Grade 1 . . . Combined Histologic Score 3 + 1 + 1. Histologic Grade for Lobular: Glandular Differentiation Score 3."

The ILC has an "Overall Grade" of 1 or overall "Low grade." Again, please confirm it with your team.

The overall grade appears to be based on a combined histologic score of "3 + 1 + 1".

The sub-score "3" appears to refer to the "Glandular Differentiation Score" of "3", presumably in light of a low extent of glandular/tubular structures in the ILC.

The other sub-scores (1 + 1) likely refer to the nuclear and mitotic features of the ILC.

The three sub-scores (3 + 1 + 1) were added up to yield a total score of 5, which led to assignment of an "Overall Grade" of 1.

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Re the reference to: "Pathologic Stage: pT1b and pN0"

Anatomic staging under the TNM system considers three elements: Tumor size ("T"); Lymph Node status ("N"); and evidence of distant metastasis ("M").

p = "pathologic" (i.e., based on surgical pathology)

pT1b = refers to the size of the largest invasive tumor on surgical pathology: "Tumor > 5 mm but ≤ 10 mm in greatest dimension"

pN0 = "No regional lymph node metastasis identified or ITCs only"

(Note: "ITCs" (isolated tumor cells) if present should be specifically noted.)

If there is no evidence of distant metastasis ("M0"), then pT1b N0 M0 would be in Anatomic Stage IA. Please confirm it with your team.

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Although the grade of the DCIS is "high" and the grade of the ILC is Grade 1 (out of 3), the ILC is the more severe condition, because it is an invasive breast cancer and as such, presents a risk of distant metastatic recurrence.

Radiation is a local treatment.

Decisions about radiation entail a personalized risk/benefit analysis, including an estimate of the patient's estimated risk of local recurrence in light of all relevant factors, such as the type(s) of disease present, size(s) or extent of disease; margin sizes; grade; patient age, and medical history, including certain co-morbidities. The potential benefit of radiation is proportional to your risk of local recurrence, and the potential benefit should be weighed against the potential risks of treatment in your case. Your Radiation Oncologist should provide this type of information.

With invasive breast cancer, chemotherapy (if it were recommended) typically precedes radiation therapy. So please arrange to meet with Medical Oncologist in parallel to obtain expert advice regarding recommended systemic drug treatments, such as chemotherapy and/or endocrine therapy (for hormone receptor-positive disease (ER + and/or PR+)). A person with node-negative ILC that is 8 mm in size, ER+, PR+, and HER2-negative is reasonably likely to receive a recommendation for endocrine therapy alone.

Best,

BarredOwl

Veeder14

Thank you so much Barred Owl for taking the time to write me back. My referral to the MO is in progress and I will take what you wrote to my appointment and get my questions answered. I want to be able to make an informed decision. I got the impression from the surgeon that DCIS was worse than lobular type and the reason for the radiation referral.

BarredOwl

Hi Veeder14:

From a same breast local recurrence perspective, both the ILC and the DCIS must be adequately addressed by local treatment(s).

Because DCIS is non-invasive, it is not considered to pose a risk of distant metastasis. Instead, the main focus with DCIS is adequate local treatment.

Typically, invasive disease (e.g., ILC, IDC) warrants radiation following lumpectomy, and that is often sufficient to treat any accompanying DCIS as well.

In the exceptional case that radiation was not be recommended on the basis of the ILC, the question would become whether the DCIS separately warrants such treatment (because the DCIS poses its own risk of local recurrence). And that would depend on factors such as the extent (size) of the DCIS, the grade of the DCIS, and the surgical margins for the DCIS. You can check your pathology report for this type of information for the DCIS.

BarredOwl