Trying to make sense of surgical pathology changes

emstein

Hi, I'm hoping the wise folks on this site can help me with some questions. I had a lumpectomy on 1/4 and just got my pathology report back yesterday. The good news is that the one sentinel node they found and took out was negative. Also margins were clear (but she did have to take a lot more out than she thought, had a hunch during surgery.)

Here's where things get a bit confusing. Originally, after mammogram, biopsy, and breast MRI, I was er and pr+, her2-, grade 2, 1.5cm, no DCIS detected, no lymphovascular invasion.

The surgical pathology says now I'm grade 3, dcis was present around the tumor, and now it's showing lymphovascualr invasion. And they retested me for Her2 because of the grade change but it still came back negative.

I know things can change after surgery but this seems like a lot. Since the margins and lymph node were clear I'm still considered stage 1a. but I'm trying to wrap my head around what's to come with this new information.

Does grade 3 automatically mean chemo will be recommended? Does grade 3 typically effect oncotype scores? Since I'm er pr+ her2-, does that mean I'm luminal type a? How did you find out your Ki-67? I don't see it on either the biopsy pathology report or the surgical pathology report. Only one lymph node was taken...should they have taken more with the grade 3 change and lymphovascular invasion?

Any insight is most welcome. I'm not panicking. I'm not afraid of chemo and if I need it I need it. I just have so many new questions....

Beesie

emstein, sorry you've had surprises from the pathology. That is, unfortunately, pretty common.

First off, don't worry about the DCIS. Most IDC, about 85%, has some associated DCIS. That the DCIS wasn't found in the biopsy and was found in the surgical pathology doesn't matter. DCIS is the less serious condition, so other than removal (which has already happened), it can be ignored. Anything done to treat the IDC will be more than adequate to treat the DCIS.

Now, to your questions:

Does grade 3 automatically mean chemo will be recommended? Absolutely not. With your pathology, I expect that your Oncotype test will be the most important deciding factor. It's impossible to know what your Oncotype score will be, but with an ER+,PR+,HER2- node negative cancer, more often than not chemo is not required.

Does grade 3 typically effect oncotype scores? Not directly. Grade is not a factor in the Oncotype calculation, which includes an assessment of 21 genetic components. But grade might affect some of those other components, so it could indirectly affect the score. ER and PR are big factors as well so being ER+ and PR+ will be helpful.

Since I'm er pr+ her2-, does that mean I'm luminal type a? I believe so.

How did you find out your Ki-67? I don't see it on either the biopsy pathology report or the surgical pathology report. Many facilities don't use/report Ki-67. Mine doesn't. If it's not in your report, it probably means that your facility doesn't use it. On it's own, Ki-67 typically does not factor into treatment decisions, however it is one of the 21 genetic components evaluated by Genomic Health when determining your Oncotype score. So your Ki-67 will indirectly be factored into your treatment decisions, through your Oncotype score.

Only one lymph node was taken...should they have taken more with the grade 3 change and lymphovascular invasion? No. First off, there was no way for the surgeon to know during surgery that your tumor was grade 3 or that there was lymphovascular invasion. But more importantly, the process of a sentinel biopsy is what dictates how many nodes are taken. Isotopes and/or blue dye are injected into the breast. Only those nodes that 'light up' with the isotopes and/or dye are removed - those are the sentinel nodes, the first nodes that anything from the breast flow into. Because of how nodes are grouped together, there is no way for the surgeon to know which nodes are sentinel nodes without benefit of the isotopes/dye. Therefore during an SNB, a surgeon will only remove those nodes that have 'lit up' from the isotopes/dye. For some people, that's just one node. For others, it could be as many as 5 or 6 nodes. In your case, it appears that you have just one sentinel node.

Hope that helps!

emstein

Oh Beesie, thank you so so much for your reply! You can't even imagine how comforting it is to have these questions answered. I really appreciate it.

Odyssey305

emstein, thank you for posting about your experience! I feel a little less alone now with my own surgical pathology surprises. I just received my report (I had a lumpectomy and sentinel node dissection two days ago) and I'm in shock after learning that I had micromets in 1/5 nodes. I'm now considered stage 1B and at the higher end of grade 1. While I understood that the big picture can, and often does, change after surgery, I wasn't mentally prepared for this news. Throughout this whole ordeal of scans/diagnosis/treatment planning, etc. I've been mostly calm, but seeing micromets on my report has unleashed a flood of worry. I've been trying to stay positive and focus on the fact that this was discovered early. But this feels a lot like pandora's box - who know what other surprises are in store for me. This also may throw my surgery + rads plan out the window, but honestly I'm ok with whatever my onc recommends. So many people have gone through this and I know I will get through this too, it just sucks to feel like the ground beneath my feet keeps shifting. All this to say, I understand what you're going through!

Bessie, thank you so much for the information! I've been lurking on this forum for awhile now, and I've been so grateful for the knowledge and insights you share!

Best wishes and healing vibes to you both!

AliceBastable

Odyssey305, I had a surprise micromet in my sentinal node, which was the only one taken out. It did change my radiation from the initial plan of 22 sessions to 33, but I didn't have any issues with radiation so it wasn't a big deal. My MO thought I'd need chemo, but we were both pleasantly surprised when my Oncotype came back with a 17, so no chemo for me.

With only one node affected, and since you've already had your lumpectomy, what surgery do you think would be affected?

Odyssey305

Hi AliceBastable. That's a great question. Initially, before discovering the micromet, I thought lumpectomy and sentinel node biopsy was all that was needed surgery-wise, then at some point rads and endocrine therapy. Once I got my final report I worried that the micromet may indicate an auxiliary node dissection (I got that from the NCCN guidelines, but I think I misinterpreted that). But as I was typing this my surgeon called to let me know that additional surgery is not necessary, given that it's only in one node and so small (1mm). She also mentioned that chemo may be in my future, but that will be based on my Oncotype and MO recommendations. Fingers-crossed for no chemo, but then again, maybe throwing the kitchen sink at this thing is the way to go. BTW, I love your signature line about life being boring! That's my goal too and I promise to never take boring for granted again!!

emstein

Hi Odyssey, Sorry I'm just seeing your reply now. It looks like we're reluctant members of the same sucky club. It's been a month since you replied so I hope the pieces are coming together for you in a way that feels ok.

My update is that I had my first appointment with my medical oncologist on 2/4 where she said that usually she wouldn't recommend chemo but she's questioning this for me due to 1. my age (44), 2. lymphovascular invasion, and 3. the change from grade 2 to 3. So, after that appointment she ordered the oncotype test to help make the decision. It's now 3/4 and I'm still waiting for the results. I'm starting to get antsy- I was diagnosed on 12/8, had surgery on 1/4 and now, 2 months later, I still don't have a finalized treatment plan. I wish they had ordered the oncotype right after surgery. Le sigh.

Odyssey- can I ask you a question? I see you had an ovary removed. Can I ask if that was related to your breast cancer diagnosis? I was planning to speak to my gynecologist about that when I see him later this month. I don't need them anymore and I've had problems with cysts. My med onc didn't think it was a bad idea necessarily but suggested I speak to my gynecologist, too.

Odyssey305

Hi Emstein, it's good that you met with your MO, at least to get an idea of what she's thinking. It sounds like your Oncotype will be a big factor in treatment, which makes the wait SO much harder. I'm really sorry it's taking so long to get your report, one month does seem like a long time! I've read posts from other women who have contacted Genomic directly, so this may be an option for you too.

You asked about my oopherectomy. I actually haven't had this surgery yet, but it's planned for after rads, so sometime at the end of April. But yes, it is a part of my BC treatment. My Oncotype score came back with an intermediate score of 17, but showed no benefit of chemo. MO felt like the best way to go is ovarian suppression + AI, but she also strongly recommended that I have my ovaries removed sooner rather than later. I think this was partly based on my estrogen level, which is/was pretty high. So for now I'm on ovarian suppression while I wait for surgery, which has been like menopause lite. I was really dreading another surgery, but I've read that it's a fairly straightforward outpatient procedure, and it will save me potentially years of ovarian suppression meds with better results. I think speaking with your gyno is a great idea, especially since cysts are a potential side effect of hormone therapy.

Take care and keep us posted on your next steps!

pattik

Hi Emstein. When I was having trouble getting my Oncotype results from my doctor, I just called Oncotype. That's when I learned my original MO hadn't ordered them when he said he had. I believe I had to sign a document and email it to them, but they emailed me the results. Sorry I don't have the number. I believe I found it on their website.

My current cancer center pushes for chemo starting within 60 days after surgery, however they said some MO's use 90 days as the benchmark. One of the studies is on Pubmed and is called "Delayed Initiation of Adjuvant Chemotherapy Among Patients with Breast Cancer".

My cancer center doesn't use Ki67 either. Mine was 40 (quite high), but my MO said there is just too much variability in testing to make it useful on it's own.

emstein

Hi Pattik and Odyssey,

Thanks for the advice! I was just about to call the Oncotype folks when my oncologist called with my results. My score is 18, so less than 1% benefit of chemo. Woohoo! I'm so relieved.