Pleomorphic LCIS
Comments
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I have extensive PLCIS left over in my breast after the lumpectomy to remove my pleomorphic ILC. Tumor board hemmed and hawed for quite awhile, first recommending bilat mast, then backtracking and telling me I could leave the PLCIS in there. But one thing I wanted to point out was that my surgeon did tell me that the radiation I was having for the PILC would have no effect on the PLCIS.
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Can you believe that science can be so unclear? I too have "fuzzy" diagnoses. Last year, my diagnosis changed from LCIS (MRI core biopsy); to DCIS (second opinion); and then to PLCIS and Classical LCIS(excisional biopsy and re-excision). My BS also said PLCIS is usually treated like DCIS and he recommended tamoxifen and radiation. The radiation oncologist said he did not recommend radiation since the final diagnosis was PLCIS/LCIS. I have been monitored every 6 months with exams/mammo/MRI. I also visit a High Risk Assessment Oncologist. She also suggests tamoxifen.
Last month, the diagnosis for my other breast was radial scar and AH (MRI core biopsy). I will be having another excisional biopsy at the end of the month.
I would appreciate any information you get from your oncology consults.
Thanks
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I'm 45 yrs old and just got a diagnosis of pleomorphic LCIS (PLCIS) along with a bunch of other things like complex sclerosing papillary lesions and flat epithelial atypia - all found on steriotactic biopsy prompted by microcalcifications on mammo and positive BSGI scan. Radiologist referred me to surgeon for excisional biopsy. I have appointment Tuesday w/ BS and Oncologist. I'm just beginning this whole process. I'm just beginning what looks like will be quite an uncertain path...
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Since PLCIS is a 'recently described entity' (according to this abstract in 2006) http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1828915
its no wonder we do not know how to handle it or classify it. Plain, classic LCIS was first described in 1941.
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I had my consult at Mayo Clinc on Thursday re: my PLCIS. I am still processing what I was told, which wasn't much.
I will not relate the thoroughly frustrating time I spent with the gal who was obviously an intern and told me that my chance of getting cancer in my other (non PLCIS) breast was 10% - which I know is absolutely not true (okay, I'll relate a little bit). I told her I'd seen quotes of the risk in the contralateral breast as much higher than that (7 X or more the general pop.). She asked me where I got that info, and I pulled out my article on LCIS from Mayo online. Then she said, well that's if you've had ILC. I pointed to the title of the article: Lobular Carcinoma in situ. Then she said she'd have to consult with the "breast specialist" and left my husband and I in the examining room for 45 minutes. I thought this must be good, as now she was really discussing my case with someone who knew.
She came back and began drawing pictures of the breast and the ducts vs. lobes. She said I should just ignore all of the "big words" in the pathology report and that "pleomorphis LCIS" only had meaning to pathologists and had no impact on me or my cancer. It was only description, with no impact on treatment. I had a list of questions, which I tried to go thru with her, such as if PLCIS would more likely be a marker for PLC, etc. It was so frustrating that I can't even convey how upsetting the whole thing was. It felt like she was talking down to me and thought I was looking for bad news, or something. I told her that I was now more confused than ever.
She left the room again and I burst into tears (which is not like me, believe me!). Here I had come to what I consider the best clinic on earth, and this is what I was getting! These were the folks to whom my slides were sent 2 years ago who identified the PLCIS and spared me radiation and chemo, after all! Sorry this is getting long and is sounding like just me venting (which I am).
Finally, the "breast specialist" comes in. Finally I felt I was being heard a little bit more. But the thing I realized is that, unless a subtype of breast cancer has also had differential treatment trials and replication of those trials, it does not exist for the oncologist. The classifications are just words. PLCIS is the same as LCIS for them.
In retrospect, I think it never occurred to the young intern that I might be asking about the advisability of PM on the other side. She was a very young, attractive woman, and eventho I'm 99% certain I mentioned this as something I was considering, perhaps she blanked it out. And if she didn't consider this as a viable treatment, why was I even inquiring about a subtype of LCIS for which there is no other treatment than there is for plain old LCIS? Why not just quit worrying about it?
The guy, on the other hand, understood what I was considering. Regarding whether PLCIS is more likely a marker for PLC than other forms of invasive cancer, he very barely indicated it might be - but so wishy washy a response that my husband does not remember this at all. This was one of my big questions, since PLC seems to be a very nasty cancer. The doc would not acknowledge that PLCIS and PLC are any more aggressive than any other types - didn't answer one way or the other. In fact, he said that they don't even differentiate PLC from any other kind of breast cancer. Again, I think because there is little research.
He said that PM is a "reasonable" option, along with the option of careful surveillance. He seemed to have a lot of faith in surveillance and catching anything else early. Asked what he'd recommend for his own wife or daughter in my circumstance, he said he's recommend surveillance. He told me that the risk of cancer in the other breast is twice the general population - so 25%. Surprisingly, he is not a big fan of tamoxifen and said it has not been shown to increase long-term survivial - which I do not get at all, since my onc says it cuts recurrence rate in half.
I got the feeling that most of the advantage he sees of PM in this case is psychological, tho I asked him several times if it made medical sense as well as emotional. He conceded that it did, and that, then, the risk of cancer in the other breast is less than 5% vs. 25%, and that's about "as good as it gets."
So that's where I'm left. If I remember anything else, I'll add more. This has surely been emotionally draining. I thought I wanted to be told what I should do. Then when I listened to the intern, I felt she was telling me what to do - just go home and not worry, and that she was taking away my choice for a PM. I found that very upsetting, plus I had no faith in her knowledge whatsoever. With the breast oncologist, I felt that he was giving me two very real, logical choices. But he certainly didn't tell me what I should do. And, in fact, he said he would never tell a woman that she should have a PM because it was a personal decision. So now I'm back to uncertainty. And maybe knowing that I really didn't want to be told what to do. And with perhaps a little more faith in surveillance - but maybe misplaced... We're going to get another opinion. But where do you go from Mayo?
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Oh minnesota! I'm so sorry this happened! Believe me, I can relate, even though I only have classic LCIS.
At my 2nd opinion, at a Major institution (not as prominent as the Mayo), I was told my risk (I have classical LCIS) was 'somewhere between 10% and 60%, but probably closer to 10%.'
As you know, the risk of the average woman in the US isn't 10%. Its more like 12%. Surely my LCIS and ALH put me at some increased risk of bc.
I knew I was not going to have a good time when the NP started out with 'We use a breast cancer risk calculator called the Gail model'. I finished her sentence with 'which specifically excludes LCIS.'
From what I understand, when they say one's risk is 7x normal, that is 7x the risk of the normal, average woman, who has no particular risk factors for breast cancer - besides being a woman. This figure is not 12%, but more like 3-5%. So 3-5% x 7 = something like 25%.
I am so sorry this happened to you.
I have heard at least 2 LCIS patients who said they get followed at Duke and were pleased with their care. That's pretty far for me to travel, or I'd be followed there. One poster said the high risk bc number for Duke was 1-888-ASK-DUKE (1-888-275-3853) and ask for the High risk breast clinic.
I'd advise going to somewhere that is studying PLCIS, or at least LCIS, but I don't know where that is.
You have EVERY right to be upset.
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I was reading this thread and thought I'd just share a conversation I had with my oncologist. Before I do, please understand that my situation is NOT like yours. I was diagnosed with invasive pleomorphic lobular cancer in my left breast. My pathologist said it started as DCIS, was not found on mammograms (because there were no calcificationsn and no necrosis) then progressed to PILC, was still not found on mammograms for years. After chemo and mastectomy for the PILC was completed I had a conversation with my oncologist about having my other breast removed. I asked him if having MRIs would catch breast cancer in the other breast before it becomes invasive (as mammograms certainly didn't help). HIs answer was that it would not catch LCIS before it became invasive. It would probably catch DCIS before it became invasive. Having had one invasive breast cancer, I didn't want to risk another. I have had the other breast removed, too.
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This study was done at Pittsburgh. They say there is no concensus for treatment, but it sounds like they're interested in PLCIS. http://www.ncbi.nlm.nih.gov/pubmed/18769331
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I received a diagnosis of DCIS which was changed to LCIS after a lumpectomy. After the pathology I was told it was PLCIS. My onco surgeon took my case to a tumor board and she told me either the bilat mast or monitoring every 6 months would be the best two options. After much discussion plus a meeting with a medical onco I made the decision to have the bilat mast.
I was told the LCIS only is found under a microscope so I didn't want to have the 6 mo checks waiting to see if it had become invasive. Just didn't want to play those odds. I also had 1 mm margins on the PLCIS lump that was removed so expect there to be additional LCIS in one or both breasts.
Maybe with more diagnoses of PLCIS and more women chosing different options there will be more research done and more consensus of opinion in the future.
My surgery is June 16. Thanks for everyone's input. It was helpful hearing what you all have been through and what the various docs have said.
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I was dxed with PLCIS of the right breast in April, discovered by calcifications on mammogram. Had excision bx, guided by wire placement into the calcifications, placed by a radiologist guided by mammograms directly before sx. The margins were clean, but narrow, so had second sx on 5/19. Consulted an oncologist, who presented my case at a tumor conference on 5/27. I spoke to him today--he stated that PLCIS is a gray zone, more like DCIS. He stated that the consensus was that it should be treated like DCIS. (This is consistent with what I have read.) He informed me the 2nd bx was negative. He has referred me to a radiation oncologist, my appt is Thurs 6/4. He plans to start Tamoxifen afterwards. I suggested Evista (I am 60 and presently taking Boniva to prevent osteoporosis), but he favors Tamoxifen. Thanks for all the intelligent and insightful discussion.
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After consultation with radiation oncologist, he presented my case to breast tumor board. He advised me on 6/5 that the consensus was not to offer radiation. He said there was heated discussion, and disagreement. He personally would offer radiation for the PLICS. I am leaning towards radiation followed by Tamox. Has anyone had radiation for PLICS?
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I had pleomorphic ILC removed via lumpectomy, and I have extensive PLCIS left over in the breast. My surgeon told me that the radiation I'd be receiving for the PILC would have no effect on the PLCIS. She had recommended bilat mast b/c of the PLCIS (she trained at MD Anderson, and that the standard of care for PLCIS there), but then tumor board decided I could leave the PLCIS in there, and I ended up just going with lumpectomy. I'm 2 years out from diagnosis of the PILC, and so far the PLCIS is stable
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petdoc
will write a longer response later, but for now... i had plcis (found in core needle biopsy), followed by two lumpectomies to remove it to show clean margins. my breast surgeon told me to have radiation. since i did not have a good relationship with her, i let everyone i know my predicament. finally got in to see two top radiologists in new york city. the tumor board at the first hospital - after reviewing all slides, etc. - did not recommend radiation. neither did the second hospital. in fact, they never radiate plcis. nor do they radiate dcis. so, i decided to go with the decision to not radiate and to have a yearly mri alternating with a yearly mammo and sonogram. i found an oncologist whom i like and she is having my blood tested to see whether i can metabolize tamoxifen; and because my ethnic background has a high percentage of breast cancer, to have it genetically tested.. i think it is important to find an oncologist that you like and trust so you feel comfortable with whatever decision you make. i am currently following a two month tibetan herbal treatment to cleanse my blood down to the marrow level. i was also advised to do daily healing mediatation.
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Nash,
The tumor board that you spoke of, where they debated what to do about your PLCIS - which hospital was it? I'm just curious where and how often PLCIS is even being talked about. It seems as tho their decision focused on your PILC rather than your PLCIS. I wonder what they would have recommended if it were "just" PLCIS. Also, you mention a standard of care being developed for this at MD Anderson. Do you know what they base their recommendations on, if there's no research? Even if there isn't any "research," I would think there would be some sense, maybe even from the pathologists, what this animal looks like to them - in terms of how many fangs and claws it has...
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Hi, Minnesota--
My tumor board was based at UC San Diego, with some members of an outside oncology group sittting on it as well. Like I said, my surgeon trained at MDA--they have their surgical handbook online through google books, and here's a link (sorry it's not live) to their very brief section on PLCIS:
In case that very convoluted link doesn't work, basically, they just say that they think PLCIS progresses to PILC, and therefore should be excised. Since my PILC was surrounded by PLCIS, my PLCIS probably did progess to PILC. That being said, following my lump/rads, the area around the lumpectomy site is completely stable 2 years out.
If you google pleomorphic LCIS, it seems that most of the studies have ben done at MDA. Just from my reading, it appears they are the only institution in the US with a clinical interest in it.
I just switched to a new onc at the beginning of the year, and she blew the PLCIS issue off. She didn't give a reason--she just was comfortable with monitoring it.
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Here's a link to a PDF file that shows slide of how PLCIS looks compared to LCIS and DCIS--it's rather interesting:
http://mrc-holland.com/WebForms/WebFormDBData.aspx?FileOID=5n\OzqO7fyQ|
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Nash,
Thanks so much for the links. They work. I'll definitely be doing some reading!
Eve
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Thanks for the info on PLCIS Nash. I wondered how the pathologists determined whether it was pleomorphic or classic LCIS. I asked for a second read on my path that was LCIS and now after seeing those slides I feel a little embarassed for asking. Seems clear the differences under the microscope between classical and pleomorphic. Oh well guess having a tumor board review your case can never hurt...I hope that is true.
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Cleomoon,
You shouldn't be at all embarassed for asking for a second read. First I had a diagnosis of DCIS, and then it changed to PLCIS. The pathologist here sent it out to Mayo for that second read. I don't think anything is clear where LCIS is concerned. This whole thing is driving me whacko!
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I have been reading the boards and I thought it was time I weighed in. I was dx with PLCIS in Jan 09. Started with microcalcifications on mamo, biopsy and excision, followed with second excision to try to get clean margins. Did not get clean margins. Saw two oncologists. First had not treated a PLCIS patient, recommended further excision to try to get clean margins followed with radiation ( ie treat it like DCIS). My surgeon did not agree with this since PLCIS was pretty extensive in right breast. I then saw an oncologist that specialized in DCIS/LCIS, he had only seen two cases of PLCIS. He explained the risk factors to me using the Van Nuys risk index. I have also done extensive reading and research of this topic. I have decided to go ahead and have a mastectomy rather than being sliced and diced until they can get clean margins.
Unlike the classic type of LCIS the pleomorphic type is rare. The cells are very large, abnormally shaped with necrosis and calcifications. Everything that I have read describes this variation as looking very aggressive. What data is available seems to link PLCIS with invasive lobular carcinoma and especially with the pleomorphic lobular carcinoma.
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Macksix,
Thanks so much for your post. Any additional info on this is much appreciated! Can you talk a little more about what your oncologist had to say about this and about the risk factors, and do you have a link to the Van Nuys risk index? What is his take on the mastectomy and are you having bilateral?
Thanks!
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You can google Van Nuys breast cancer and get information.
It is a measuring tool to help predict the risk of recurrence ( using statistics) for DCIS by looking at the age of a patient, size of tumor, grade of tumor and extent of clean margins. In my case the pleomorphic grade , size and the fact that we can't get clean edges gave me a 10 range out of 12. My oncologist told me it was not a mater of if I would develop cancer but when.Now the study was originally done on DCIS patients but PLCIS has to be treated along the same lines as DCIS due to the aggressive nature of the cells.
I will be having a bilateral mastectomy. PLCIS is associated with invasive lobular cancer. This type of cancer often does not have a mass or tumor. It is more likely to show up as a thickening in your breast. I have large, dense, fibrous breasts. My oncologist said you can't see a darn thing with the mamo's. You hear of woman all the time that just had a mamo a few months back and are now dx with cancer. It is sneaky not like other cancers.
If you have a small area of PLCIS that is able to be excised with good clean edges you should be OK with that and monitoring.
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Macksix,
Does your recent oncologist think there is a link between PLCIS and invasive lobular cancer? What is his opinion on having the bilateral procedure vs. just on the side the PLCIS was found?
Thanks!
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The first oncologist consulted with the doctors at UCLA and he said quoted from his report to my breast surgeon " If she has further re-excisions that continue to show persistent disease with involved margins, we would recommend a mastectomy."
The second oncologist who specializes in DCIS/LCIS quoted from his report "I reviewed with the patient the nature of PLCIS characterising this as a relatively new entity, separate from classic LCIS. I reviewed with the patient that there are distinct molecular markers that have been identified which can evolve into invasive pleomorphic lobular carcinoma, which is a significantly more aggressive form of lobular cancer, which may not respond well to hormonal therapy, and has a more unfavorable prognosis then classic invasive lobular carcinoma.
"I indicated to the patient that the majority of opinion in this admittedly uncommon entity is that these patients should be handled more like ductal carcinoma in situ. I reviewed the clinical characteritics of classic type LCIS, which is handled more as a marker, rather than a precursor lesion.
Given the different clinical characteristics of PLCIS, I therefore have suggested to the patient that the optimal therapy woulld be a total mastectomy"
He aslo went on to say "that given the contralateral nature of LCIS it was not clear whether this contralateral presentation was equally an issue in PLCIS but that the risk may be as high as 30% over her lifetime." He also said that lobular cancer is difficult to find on mamo's it usually show up as a thickening and is often missed.
What is important is that PLCIS is not LCIS, it is much more of a concern and should be treated like DCIS. The cells are very large (3X normal) abnormally shaped with calcifications and necrosis. If you can get clean edges during excision then you should be OK with that and perhaps some radiation. In my case we can't get clean edges.
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Mack6,
Thank you so much for your response, and especially the quote from your report. It is extremely helpful to me, tho of course, scary. But what is there about cancer that isn't scary? It's all about gathering information and going with one's best educated guess, especially when dealing with a cancer about which there is so little information. One of the questions I have had is if it is likely that PLCIS would evolve and/or be a marker for PLC - which does seem to be an especially bad cancer. This is the first time I have heard a definitive response from an oncologist that there is a relationship, as seen at the molecular level. Also, the info about that cancer not being especially responsive to hormonal therapy is significant. Those are two very important points that will weigh heavily in my decision whether or not to have prophylactic surgery on my other breast. I can't thank you enough!
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Minnesota you appear to have LCIS. Is it the classic type? If so you may be fine with monitoring it. My oncologist said that classic LCIS is a marker that may increase your risk of developing cancer. A normal woman has about a 12% chance of developing cancer with LCIS your risk may increase to 18-20%. It is pleomorphic LCIS that is more of a concern and thought to be a precusor to cancer.
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Macksix,
I do have pleomorphic LCIS, as dx'ed by Mayo Clinic. At first it was thought to be DCIS, but then it was sent to Mayo because it was so unusual looking to everyone here, and they gave the amended diagnosis. I had unilateral mastectomy on the one side and didn't actually realize I had PLCIS until much later, after my recon at NOLA, and when I finally looked at my pathology report. Since then, I've been trying to understand what PLCIS means. I was treated as tho it was DCIS - couldn't get good margins in lumpectomy, then mastectomy. I didn't realize until later that I actually had LCIS and that it increased my risk in the other breast. I've been researching this with much frustration. Coincidentally, you met with my friend Sandy about NOLA, and she knew I had PLCIS and that your doctor and hers (the same) specialize in DCIS and LCIS. I subsequently e-mailed him about this and the advisablility of a PM on the remainng side. He was very helpful and informative. But I did forget to ask him about the PLCIS and PLC connection, and he also had not mentioned hormone therapy being not as effective on PLCIS - which is what I have been on. He also quoted me the 30% figure. I have dense breasts. My PLCIS was 4 1/2 cm and it barely showed up on the mammo and ultrasound, even tho I have small breasts. There was no lump. They found another area in the same breast when they did the mastectomy. So, yes, I do have pleomorphicLCIS and my concern at this point is living with the risk of it occurring in the other breast and not being detected until it is large or has possibly evolved out of my lobes and ducts. I'm not that old and have many years ahead to be monitoring this - not sure I want to have the risk and worry. Especially when I know I can head down to NOLA and have a great cosmetic outcome.
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Macksix,
I'm only assuming you're the same gal who met with Sandy, as the things I told her you had written were so close to what she said the gal she met told her. And that you're in Calif. The main thing was the pleomorph thing - which is so rare - and that Sandy knew her own doctor specialized in DCIS and LCIS, like the one you said you saw. Also that you were looking into prophylactic surgery, as you posted here. But I could be totally wrong and this could all just be coincidence!
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WoW. Small world. Yes I recently met Sandy as a mater of fact we are going to the FORCE meeting together this morning.
Yes it has been very frustrating to get information on PLCIS. LCIS is not that common but PLCIS is very rare. Many patients are first dx with DCIS since the molecular structure looks the same. It has only been since 2003 with the E cahden stain that they can tell the difference. The lack of this stain signifies that it is lobular in nature.
With that being said lobular cancers are the sneaky ones that are hard to detect since there is no mass or lump. I have PLCIS in my right breast and both oncologists recommended mastectomy. I was told that my left breast is at greater risk. I have large (36D) fibrous, dense breasts and I just don't want to risk it. I would have to have surgery anyways on the left breast because I want to be smaller and I would need to adjust the left breast so I have decided to go with the bilateral.
I am hoping to have my surgery at NOLA and have all my paper work etc in to them but insurance may play a part in whether I have the surgery there or not. What type of surgery did you have and how was your recovery?
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MackSix,
I had stacked DIEP. The recovery was not easy. I was stretched pretty tight and couldn't stand up totally straight for some weeks. I think that totally depends on your body and how much fat they need to take. I didn't have much. The thought of going through this all again is pretty daunting. But the risk of getting cancer in the other side - and possibly an especially bad one, as well as chemo, etc. is worse. Be glad you're going into this with way more knowledge than I had and getting both taken care of at once. You've made a wonderful choice with NOLA. I sure hope your insurance comes thru for you. The only thing that makes the thought of a second round of this tolerable to me is that I know the folks in New Orleans will do a tremendous job, and if anyone can get another breast for me out of the little extra fat I have, it's them!
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