Lymphatic invasion

Pines · August 2009

Hi Kate,

I was glad to see your update and very glad that your second review was more favorable. I am still waiting for my oncotype score. My oncologist, surgeon and naturopath all said that because of my tumor size (1.7cm), lymphovascular invasion and age of 39 they suggest chemo regardless of no node involvement. They are recommending 4 rounds of TC. TC may be because of my bigger tumor size. I haven't heard of CMF, but then I hadn't heard of any of this until I was diagnosed with bc! They did tell me that lymphovascular invasion is generally not as bad as having a positive lymph node. Did your doctors say the same thing? I am scheduled to start chemo on Tues, Aug. 11, but I'm not sure that I can go through with it if I don't have my oncotype score back yet. Maybe I need peace of mind - but I'm not sure that a low score would avoid chemo anyway, so....? All of these decisions in such a short time!

I wish you the best in making your chemo decision. After my chemo, then on to the tamoxifen decision...

Shay

Kate2z80 · August 2009

Shay, that sounds right to me. My first oncologist said that if my onco score were higher, he'd recommend 4 rounds of TC. My second oncologist said that if my tumor were larger than 1cm, she'd recommend chemo. Part of the softening of her recommendation to a suggestion was the fact that the second look at the pathology was more favorable than the first look.

Good luck with your decision. Haven't made mine yet, but leaning toward it. Started Tamox last week, without any problems (yet). I have had a couple of mystery bruises, but nothing major. I think it takes about 6 weeks for side effects to surface, if you're going to have them. So many new challenges!

Kate

Pines · August 2009

Hello,

I writing to update on my situation also. I posted on the chemo board for input. My oncotype score came back as a 6 (just got it this afternoon). So, now what...? I don't know what to do given the LVI and a tumor size of 1.7 cm. I meet with my oncologist tomorrow.

Kate, I know that your tumor is smaller than mine, but otherwise, we seem to have similar diagnosis with low onco score and LVI. Have you decided on chemo yet?

Shay

Angel10 · August 2009

Shay,

For what it is worth...I had lymphatic invasion with infiltrating ductal AND tubulolobular CA....2.3cm tumor...no nodes, but the BS took out 15 to be sure! I think the lymphatic invasion must have been pretty impressive if she went after so many nodes after the SNB came back negative! Anyway, my oncotype came back at 18...11% chance of reoccurance. I said NO to chemo. I did have a bilat mx, so thought I gave it my best shot that way. I have 3 sisters that had more extensive disease that did chemo and each of them have short term memory loss...AKA chemobrain. I figured if my score came out low, I was going to try and do everything I could to avoid that. I need to get back to work soon and need to have all cylinders available for that.

It is an individual decision just as my bmx was. I had 1 good breast, but decided I did not want to wait for that one to go bad, so took it off. I wish you luck on your decision...there is no wrong decision...just what is going to give you the quality of life and worry that you are willing to live with.

God Bless!

Angel

Kate2z80 · August 2009

Shay, I haven't made a final decision yet, but am leaning toward doing the CMF ("chemo light"). I have an appointment with my ongologist in two weeks (he's on vacation this week and me next week), which was the earliest I could get. I'm pretty sure I'm going to do it and was sold pretty much when I was told that there would be minimal hair loss (had no idea how vain I was 'til this came along). Seriously, though, if the breast cancer specialist had recommended TC, I would do that, too.

Good luck tomorrow. What a great (low) Oncotype score!

Kate

Helen-Jackie · August 2009

Hi Ladies

i posted in another category as i didnt see this one.. so here i go again

I just got back my pathology report and I live in Canada so options or tests might be different than in the USA, although i would go there if i needed to.

So. I have been reported to have ER+,PR+,Her 2- and a 1.2 cm tumor size with no lymph nodes involved.. the margins were all nice and clear at 3mm to 4mm. I am 51 still getting very regular periods.

so that is all good, but the report also said lymphovascular invasion present ant that there was a very focal point noted. So that freaked me out, because I was being lead to believe by the surgeon that i was in a good position, probably not even needing Chemo, But then he never spoke or perhaps read the fine print of this pathology report that noted lymphovascular invasion. being present.

So now i am freaked that perhaps the cancer spread thru the blood system and stuff on the net said that prognosis is worse by alot, and there is a greater chance of recurrance elsewhere in the body.. yikes

I am wondering if anyone else had a similiar report and how they are doing, what treatment did they have and when. Also did your patholgy report get further tested on this point by another techinique other than H&E staining.. ie d2-40, (not w40lol) or c31,c34 etc.

I thought they can get better reliability to these additional test but not sure if they will test it further.. what did your oncologists say...

thanks ,,love to all

SueTacoma · August 2009

Helen-Jackie,

I was diagnosed 5 years ago, 1.7 cm, grade 3, stage 1, with no node involvment. I also had focal lymphovascular invasion. ER+/PR+, HER2-. At that time, the Oncotype testing was not available, I went through does dense AC chemo. I think for your situation, please do the Oncotype test, to use that as a reference.

So what does focal mean here? If it is not focal invasion, what other type of invasion would be?

Helen-Jackie · August 2009

Hi

thanks for the note. I was wondering why you are stage 2 when your nodes werent involved.

SueTacoma · August 2009

Hi Helen-Jackie,

If you are asking the question to me, I am stage 1, not stage 2. My understanding is that if the node is clear, but the tumor size is over 2.0cm, it will be staged at stage 2.

Sue

KarenVW · August 2009

Hi everyone!

I just saw this discussion thread and thought I would share something that helped me with my chemo decision. As you know, there is much controversy about the potential benefits of chemo for Stage 1, <2cm, ER+ PR+, HER-2 neg breast cancer. I have seen several articles where the medical community have stated the American Cancer Society's benchmark for chemo is now outdated (their benchmark for chemo is any tumor >1 cm ). Many have referenced the St. Galen guidelines which were recently updated at their annual conference in Spring 2009 (hot off the press). This year 43 oncology experts from across the world met to discuss this very topic and updated the St. Galen guidelines for chemo. All the big NCI hospitals were represented. Below is the link to the write-up of their discussions, etc. If you scroll down to Table 3 you will find a table that lists various factors indicating when chemo is needed, factors that indicate when chemo is not needed, and factors that don't make a difference in the decision.

http://annonc.oxfordjournals.org/cgi/content/full/mdp322#TBL2

For me grade 3 was the tipping point. I am doing 4 rounds of TC and just had my second treatment today. So far not too bad, just a bit sick for about 3 or 4 days. Note, the table does list peritumoral vascular invasion as an indication for chemo. Hope this helps and best wishes to all of you on your journey.

Angel10 · August 2009

Thanks KarenVW for popping in here and posting this site!

I will be sure to read and digest this info. Not discussed on this thread is the Oncotype test, so I will be interested in seeing how the results of that test fit into the results/factors of the tests done in yur attached link! THANKS!

God Bless!

Angel

weety · August 2009

Karen,

My surgical pathology report (from mastectomy) also did NOT find vascular invasion present, but my core-needle biopsy DID find vascular invasion "present in a few small angiolymphatic spaces." Funny how we both had this happen. My surgeon and oncologist both said that if it was stated as present, it had to have been seen by the eyes of the pathologists. They wouldn't make it up. The surgeon said it is possible that the only area of vascular invasion could have been the sample that the core biopsy took out. Rare, but possible. My oncologist said if VI is present, we can assume "the horse has been out of the barn" and almost always warrants chemo. Wish I understood more about how this VI and lymph node stuff works. My sentinel lymph node was negative as well.

Cathy

Angel10 · August 2009

Cathy,

The fact that you had a small tumor size no nodes involved is very positive. The area you will want to get familiar with is the fact that you are HER2+, and ER-. There is a lot of new info/thoughts on treating HER2+ cancers now, so search out that info if you haven't already.

Good luck and God Bless!

Angel

Helen-Jackie · August 2009

Hi Sue and all other beautiful caring females.

Thanks for the reply Sue.

I don't know if after a few years women dont log in anymore, but its unfortunate as we can learn from them

I don't know what my oncologist will say , but I suspect with the LVI it will change up the plan. I will do an Onco test AND I will go to Sloan Kettering for a second opinion and pathology. I know it takes time so in the mean time I am doing heavy naturopathic medicine and lots of yoga to keep me calm and strong..Any one else on naturpathic medicine

It appears that LVI will become a more accepted prognosis factor, alot of doctors ignore it, but those that dont are really strict on it but did say its only part of the puzzle, but to me it seems more like a dangerous wildcard.. OOPs must stay positvie, sorry.

I dont know if any light doses of Chemo are truly light, or if then they are not good..Seems like a cop out and i figure i might as well blast them cancer cells.. But maybe i am really wrong.. i just didnt get there yet so I will learn that part later..one step at a time I say to myself.

I understood most chemos have Taxol in it which is the ingredient for hair loss. Did anyone NOT have hair loss?

Do you think that if all factors (size, margins etc) lead to no chemo, then with lvi i am right in wanting to do a light dose of chemo, if you say it exists... WOuld that even help?

Who know how long this LVI has been floating around inside me so I think I will also do a bone scan and lung xray and do Chemo light. which is CMF or AC?

Does anyone know more about LVI, by what the oncologist says. The internet has alot of stuff.

lionessdoe · August 2009

They were wrong ..... new research is telling!

Breast cancer research surprise

Even teeny lymph invasion boosts risk of recurrence By Marilynn Marchione The Associated Press Tucson, Arizona | Published: 08.13.2009 advertisement Breast cancer patients with even the tiniest spread of the disease to a lymph node have a much higher risk of it recurring years later and may need more treatment than just surgery, new research suggests. For years, doctors and patients have struggled with what to do about a microscopic tumor or stray cancer cells in a lymph node. Women with "micro tumors" usually are given estrogen-blocking drugs, chemotherapy or both; those with isolated cancer cells usually are not, because those were thought to be of low concern. The new study challenges that view. It suggests that either type of metastasis, or spread, raises a woman's risk of having cancer show up in the breast or anywhere else in the next five years by about 50 percent. "This took an area that was very gray and I think made it black and white," said Dr. Linda Vahdat, director of breast cancer research at Weill Cornell Medical College and an adviser for the breast cancer patient Web site of ASCO, the American Society of Clinical Oncology. "I think it will influence treatment," she said of the study. "If we're considering treating the patient, we probably should." Dr. Daniel Hayes, director of breast cancer treatment at the University of Michigan, agreed. "It really does look like our biases are wrong," he said. "For the first time, it suggests that isolated tumor cells or micrometastases do have biological significance." Vahdat and Hayes had no role in the study, which was done by researchers throughout the Netherlands. Results are in today's New England Journal of Medicine. The study is not ideal: It just observed a large number of women rather than assign some to get treatment and compare how they fared to others who were not treated. The study also was done at a time when treatment was less aggressive and in a country where doctors had been treating breast cancer more conservatively than in the United States. In the U.S., many women with early-stage breast cancer are given hormone blockers. "The big issue is, should these patients also get chemotherapy?" Hayes said. However, not all women benefit from chemotherapy even when their risk of a recurrence is high, said Dr. Eric Winer, breast cancer chief at the Dana-Farber Cancer Center in Boston. "Patients are looking for more specific treatment" tailored to their individual tumor type - not necessarily more or less treatment, he said. The Dutch study involved more than 2,700 women with low-risk, early-stage cancer - small tumors that did not seem aggressive. All had surgery to remove their breast tumors. All of their armpit lymph nodes or a few key ones called "sentinel" nodes were removed and checked for signs of cancer. Doctors do this by examining tissue slices from the nodes and using special stains to make cancer cells show up. Larger tumors in lymph nodes already trigger further treatment. A micro tumor is a cluster of cells less than 2 millimeters - smaller than one-tenth of an inch. Most, but not all, doctors would treat these, too. Isolated tumor cells are even tinier - "you can essentially count them" in a tissue sample, Winer said - and do not typically spur further treatment under current guidelines. The Dutch researchers compared patients based on whether they received treatment beyond surgery and whether cancer of various amounts was found in a lymph node. In most cases, breast cancer doesn't return after surgery. Among women in the study who were given no additional treatment, 86 percent of those with no cancer in lymph nodes were free of cancer five years later. Only 76 percent of those with micro tumors and 77 percent of those with isolated cancer cells were cancer-free. That translates to a roughly 50 percent greater risk of recurrence if any sign of cancer was present in a node. Also, women with micro tumors or stray cells who were given additional treatment had a 43 percent lower risk of a cancer recurrence than similar women not treated beyond surgery. The differences should lead doctors to reconsider guidelines for how tumors are classified, which guides the amount of treatment a woman receives, the authors write. Now, a micro tumor is considered "node positive" cancer, warranting further treatment, while isolated cells are called "node negative." A new version of the guidelines is due out soon, Hayes said.

lindaps · August 2009

My Medical Oncologist and Surgeon agree with Doe's findings. Unfortuneately, after surgery, my surgeon told my husband and I that the sentinel node was negative. However, the final path report was different. I had 2 areas in the sentinel node which I consider almost "specks". One area is

1 mm which they considered "sizeable". The other though was 0.4 mm! However, it's like being pregnant they told me. Either you are or aren't and with these 2 areas, they considered this lymph nodes metestases. So, after almost 7 weeks of getting rid of a drain infection and then waiting for a small incisional opening to heal on the opposite side, I'm starting chemo, T/C this Friday for 4-6 rounds and then after my final course and my counts come back, I have to go back to surgery for an axillary lymph node dissection which scares me probably more than the chemo! However, I also saw the article that someone referred to that was published last week in the New England Journal of Medicine. A woman who is an exercise scientist at the University of Pennsylvania found that actually helps women with lymph edema. I looked it up on the internet and the article sounds quite sound. It was published for the public by the AP news at

http://hosted.ap.org/dynamic/stories/U/US_MED_BREAST_CANCER_WEIGHTLIFTING?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT&reload=true. I am unfortuneately quite overweight and have "been meaning" to get more active. So I started looking up on this Discussion Board information about trying to walk to improve fatigue. So, we'll see. My intent is good but I'm hoping I'll be able to follow through. Thanks to all of you for preparing (kind of) for my first T/C treatment this Friday. Linda

Angel10 · August 2009

Linda,

Wishing you much luck as you embark on the chemo train....it must be scary, but knowing there is nodal involvement for you, it is the right decision. I will remember you in prayer for strength and healing!

To the others, I want to share my understanding and have you comment if you think I am wrong, but this thread was started under title "Lymphatic Invasion" which is what I had, but that does not mean lymph node involvement which is what is being discussed in this new article on micrometases....these two concepts are not quite the same.

Repeating my situation, my BS must have visually seen the lymphatic invasion because even though my SN test came back negative during surgery, she went ahead and removed 13 more nodes than the 2 sentinels that were lit up....something must have prompted that? Because of the lymphatic invasion my onc originally said I should do chemo, but we waited for my Oncotype Test score which was 18...indicating chemo would not be all that beneficial. Sooo...no chemo for me.

If anyone has a different understanding, please share...

Thanks and God Bless!

Angel

greenfrog · August 2009

Hello - I thought you might be interested to hear of my LVI experience - when I was first dx I struggled to find info on it anywhere and spent months scouring the internet.

Anyway I was told by both my oncologists and surgeon that LVI is an unfavourable prognostic indicator. However - and this is a BIG however! - they just assume that it is because some node neg women still go on to develop mets and vascular invasion can be the only other route for spread. They have no way of quantifying LVI - as they do with lymph nodes. Apparently they also have trouble differentiating between lymphatic vessels and blood vessels.

I told my senior oncologist that I felt that my cancer was defined by being Grade 3 and having LVI. He just laughed at me and said "Absolutley NOT - your cancer is defined by being node-neg and ER+"

As I understand it presence of LVI is used as a guide for oncs to decide whether or not to recommend chemotherapy. (Oncotype testing is not done in UK as its reliability is unproven as yet.)

I spent a lot of time fretting about having this - but have now resigned myself to the fact that it is what it is and I can't not have it! I have done everything that medical science currently offers - mx, axillary clearance, chemo, rads, oopherectomy and Arimidex. Just have to hope now ....

Oh one thing I did find out was that LVI can increase the risk of regional recurrence - so eventhough I had a mastectomy I still had radiotherapy too.

Good luck!
Dx 5/2008, IDC, 1cm, Stage I, Grade 3, 0/19 nodes, ER+, HER2-

greenfrog · August 2009

Angel - over here a 2cm grade 3 lump with LVI would be a definite candidate for chemo.

When I had my SNB it lit up a teeny bit. Surgeon was hesitant to remove them all - but pathology revealed "isolated tumour cells" in SNB and I then opted for a full clearance. The recent study about ITC and micromets increasing risk of recurrence is very interesting - and another reason to opt for the chemo I think.

Angel10 · August 2009

Hi Greenfrog,

Thanks for your comments....I actually have reviewed the Oncotype research and feel fairly confident in its reliability. And I must say over here, the insurance companies are not quick to pay for "unproven reliability" tests, and genotyping is now part of ASCO's ssessment for chemo treatment so I feel confident in its utility.

I had the option to do chemo regardless of the Oncotype Score if I so desired. After watching 3 of my sisters go through chemo and suffer from long term effects (I personally was not concerned about the short term effects) I made a personal decision not to go through it. It was a quality of life issue. I am node negative and ER+. I also did go ahead and do a BMX, and will go forward wtih Tomoxifen which should lower my chance for distal reoccurance based upon my personal tumor type to aproximately 11%. I can live with that.

It is an individual choice, and I am glad to have the opportunity to choose what I believe I can live with.

Wishing you much good health!

God Bless!

Angel

Angel10 · August 2009

Hi Greenfrog,

Thanks for your comments....I actually have reviewed the Oncotype research and feel fairly confident in its reliability. And I must say over here, the insurance companies are not quick to pay for "unproven reliability" tests, and genotyping is now part of ASCO's assessment for chemo treatment so I feel confident in its utility.

I had the option to do chemo regardless of the Oncotype Score if I so desired. After watching 3 of my sisters go through chemo and suffer from long term effects (I personally was not concerned about the short term effects) I made a personal decision not to go through it if I did not have to. It was a quality of life issue. I am node negative and ER+. I did go ahead and do a BMX, and will go forward with Tomoxifen which should lower my chance for distal reoccurrance based upon my personal tumor type to aproximately 11%. I can live with that.

It is an individual choice, and I am glad to have had the opportunity to choose what I believe I can live with.

Wishing you much good health!

God Bless!

Angel

greenfrog · August 2009

Results from TAILORx trial aren't due for several years yet but let's hope that Oncotype and Mammaprint and all the others actually will provide an accurate evaluation and become an essential tool leading to more personalised treatment. At the moment I am happy to chuck everything at it.

Good luck with it all.

Kate2z80 · August 2009

Karen, thank you so much for posting that article. It is extremely helpful, particularly since it doesn't rely exclusively on the Oncotype test results for its recommendations. I have been concerned that it was being relied on too heavily in my case, particularly because that does not factor in anything about lymphatic invasion and it presumes no lymph node involvement; it only analyzes the genetic makeup of the tumor and then looks at the stats for return for cancers of the same genetic makeup. LVI does not equal lymph node involvement, but it does mean that some cancer cells have left the primary tumor, which is bad as far as prognosis.

KarenVW · August 2009

Hi everyone!

The St. Gallen guidelines I previously sent do provide several factors (such as LVI) to consider when deciding whether or not to recommend chemo. However, I have been told more than once by my surgeon and oncologist at Sloan Kettering that the BIGGEST factors related to overall prognosis are tumor size, lymph node involvement, stage, hormone receptivity, and HER2 status. Greenfrog, I think that is what your onco is telling you as well.

Helen-Jackie · August 2009

Hi Karen

thanks for that note.. it helped ease my panic. I just kept reading bad prognosis so this one is good. I will be going to Sloan for a second opinion, although i heard they are quite aggressive in their treatment plan when compared with Canada,, Then Europe is even less aggressvie so favouring more human methods.. they do a chemo mix of some sort with heat. What was your second opinion like at sloan vs your original doctor,. Is your doctor at a cancer institute? Did you go to Sloan or do it by mail? Did they do a second pathology. Is that automatic? If yes, is it different? Sorry for all the questions, answer what you want.. anything is useful

I hope when i see the oncologist next week i can report more information for all of us.. but the thing that stands out is that that St gallens speaks that most think that if node negative then LVI seems to be the way it spreads,..

night, god bless

Incidently did you have LVI too, when were you diagnosed?

KarenVW · August 2009

Helen-Jackie -- I did not have LVI. Grade 3 is what tipped the scale for me to do chemo. I am happy to share details on my experience at Sloan and getting a second opinion, and will send in a private message.

hrf · August 2009

My tumor was 2.2 cm and 4 lymph nodes were involved. However, there was no evidence of LVI. I was told that the negative LVI didn't come into consideration because there was lymph node involvement.

Helen-Jackie, I'll be curious to hear what the oncs at Sloan say. It was my understanding that treatment options are the same in both Canada and the US as we use the same guidelines to determine treatment plans and protocols.

Oncotype tests are not done in Canada because the company that does them will only do them on US patients. If they were available to us, I'm sure our docs would be ordering them.

Helen-Jackie · August 2009

hi yes please let me know about your experience, i totally understand u dont want it as a public post..thanks

Helen-Jackie · August 2009

hi hrf

Just want to tell you how Onco types testing works. Apparently, there are a few labs set up in the USA. Its not the hospitals that do the onco test.The hospitals must send out the pathology slides directly to them. There are no labs in \Canada as of yet, but there will be one day, hpefully soon.. If you are node negative and estrogen +you can get onco typed. You must ask the doctor to process it for you, you cannot do the paperwork yourself. The larger hospitals have done them,before so they can do them easily. However, in canada there is a fee.,,, about 4000, that u can use towards your medical expenses on your tax returns, So its not that the US company doesnt do it on Canadians only that we must pay for it. In the USA alot of insurance companies pay for it as if it might say them the 100,000 dollars instead of chemo they take the hit for the 4000. hope i helped

You have the right to have that test done to help u decide about if chemo treatment is right for u..

There are also some clinical trials in canada being done with onco type testing . u can see if u qualify, but then u dont really know

Tabatha00 · August 2009

Question: When my tumor was removed my path report said "extensive lymphatic vascular invasion".........after asking a Nurse Practitioner she told me that sometimes the TUMOR will have vascular invasion but that doesn't mean the invasion has gone all over your breast!!!!

I am Triple Negative, 2.2 cm, will be having neoadjuvnct (sp) chemo and then bilateral mastectomeis. I guess after my surgery I will find out more since I don't know anything about my lymph nodes other than when they did an ultrasound of my axilla nodes the radiologist and lady doing the ultrasound said they looked clear. I asked if they would know if they looked "cancerous" and they both said yes.

So, if I have chemo before surgery and then remove my breasts and have no lymph node involvement (praying really hard) does that not make my prognosis very good whether there was lymphatic invasion or not within the tumor itself......the tumor that is gone due to an excisional biopsy?

Lymphatic invasion

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