Lack of emphasis on vascular invasion
It seems strange to me that the staging criteria includes node involvement but not vascular invasion and lymphatic invasion. Especially vascular invasion. It seems to me that being node negative doesn't mean that much much if you are LVI positive. Yet there is so little talk about LVI. Even the doctors don't seem to mention it unless you ask.
Is LVI relatively rare? Anyone have any thoughts? I think I'm almost more scared of being LVI positive than node positive. (No path report yet.)
Comments
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Okay, maybe I found part of an answer to my question here: http://www.asco.org/ascov2/Meetings/Abstracts?&vmview=abst_detail_view&confID=58&abstractID=40109
Conclusions: LVI predicted SLN metastasis. LVI also significantly predicted systemic metastasis, but only when the SLN was also positive. This data support the hypothesis that primary breast cancers invade lymphatics to gain access to the systemic circulation.
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Interesting. And I really thought it was because they could not do anything about vascular invasion ... unlike the nodes which can be removed ... and that is why they didn't say much about it.
This is much more encouraging. Thanks posy1
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I did have a tiny bit of LVI present, but only found in the biopsy. The actual surgery found NO LVI. Interesting, huh? I have struggled with this whole LVI stuff since the beginning and it scares the bejeebies out of me, but I finally gave up in trying to find answers since it seemed like there weren't any. This is the first evidence that I've ever seen that specifically addresses it! Thanks for posting!
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I had it too and was super concerned. It was not present in my biopsy but present in the lumpectomy. It freaked me out. I tried to read whatever I could find but there was not much information about it and the only things I read were all negative. I asked my onc about it and she said she would have been more concerned if I had been grade 3 or her 2+. She said it is part of the equation but not the only thing to consider. I had an oncotype of 17 and opted for chemo because of LVI. I wanted to know I tried everything I could to zap any cells that got through but since I was Grade 2 no one really knew how well chemo would work as it usually works best on more rapidly growing/dividing cells. At this point I try not to think about it knowing that I did all I could do. I am also on Tamoxifen and strongly er/pr+ so I hope that helps. What bothers me is that my med onc's would not do any scans on me at all so they just made the assumption that nothing spread because I was Stage 1. I have a hard time accepting that as the scan people that have node invasion. I feel like because I was stage 1 they just dismiss me. Well it's my life and it's all very real to me. I hate that. I have been to three med onc's and they are all the same. I appreciate your post with information.
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Maria, can you keep trying to get the scans? I'm in Boston not Chicago, but my surgeon ordered the CT scans, bone scan, and MRI all right away -- before I even had my lumpectomy or staging. Believe it or not, even before we had the core biopsy results! She did it just on the basis of the U/S and mammos, which she was sure showed invasive cancer.
Hearing all the scans were clean helped me tremendously. I'm still terrified as I wait for the path report from the lumpectomy, but not AS terrified.
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Wow...MDG.....I know you!
I too had the vascular invasion and it scared me too. I was draw to this thread as it relates to my own diagnosis. The onc said it is better NOT to have it, but it is not critically relevant (not his actual words) when looking at the whole prognosis. I was stage 2 and node negative. The latter relieved me, but I then obsessed on the vascular invasion. My doctor did say that cancer can spread through nodes or the blood and we were doing the chemo and radiation and arimidex just to be sure we were attending to the vascular part. Like everything else, no promises. I am five years out and so far okay. I also had nerve involvement but you never hear anything about that. To be honest he mentioned the vascular thingy so offhandedly that I could have lost it...but I did read the path report and it was definitely there It will be good to hear from more people on what this means.
Edited to add that I do not get scans. I do get annual mri's. MDG, I would insist on a scan if that would give you comfort. Is it an insurance issue? I suppose out of pocket for peace of mind is not reasonable (I have no idea of the cost) but if a scan helped me to move on.....darn, I would get a scan not matter! I actually think my doctor would order one if I insisted. Being five years out has given me some peace of mind
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After I had Oncotype Dx done, I had a few questions for Genomic, one regarding the inclusion or exclusion of women with LVI in their initial studies. I was surprised to learn that Genomic does not consider LVI to be an independent prognostic factor. In fact, they believe that women with LVI present were included in their studies because it was not a stratifying question. I didn't have LVI but my onc said he would have recommended chemo if I had. OTOH, I have also been told that some cancers, regardless of whether they got out in to the body, will never biologically recur.
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I did find this from another thread on LVI:
http://www.dslrf.org/breastcancer/content.asp?CATID=28&L2=3&L3=7&L4=0&PID=&sid=132&cid=1104
Pathology Report
What is lymphovascular invasion? How does it differ from having positive nodes? And how does it affect my treatment choices?
When a pathologist examines tissue removed during a lumpectomy or mastectomy, one of the things she looks to see is whether cancer cells are present in any of the blood vessels or lymphatic vessels. If they are, it is referred to as vascular invasion, lymphatic invasion, or lymphovascular invasion (LVI).
A woman can have lymphovascular invasion but not have positive lymph nodes. This could be because the invasion hasn't spread to the lymph nodes or because it has bypassed the nodes and moved on to other areas of the body.
When LVI is present, doctors assume this means that the cancer has acquired the genetic mutation it needs to create its own blood vessels, a process called angiogenesis. Because a tumor that has the ability to create its own blood vessels may have already begun to spread cancer cells to other parts of the body, the presence of LVI is an indicator that treatment should most likely include chemotherapy or hormone therapy (if the tumor is hormone sensitive). -
Oh but I also found this: http://www.news-medical.net/news/20101103/LVI-in-breast-tissue-predicts-recurrence-of-breast-cancer-in-regional-lymph-nodes.aspx?page=2
Breast cancer, one of the most prevalent cancers in women, afflicts an additional 200,000 women each year and causes about 40,000 deaths annually. The disease often extends to neighboring lymph nodes, in part, through lymphovascular invasion (LVI)-a process in which cancer cells invade blood vessels or the lymphatic system-and can often translate into a poor prognosis for patients. Some scientists argue that evidence of LVI does not necessarily mean that the disease will recur in the lymph nodes after radiation to the breast alone, but research from Fox Chase Cancer Center now shows that the appearance of LVI in the breast tissue does in fact predict recurrence of breast in the regional lymph nodes.
By carefully examining recurrence patterns of thousands of women with breast cancer from records spanning more than 30 years, Wilhelm Lubbe, M.D.,Ph.D., chief resident in Fox Chase's Radiation Oncology Department, and his colleagues have now shown that the appearance of LVI in breast tissue predicts the future recurrence of cancer to nearby lymph nodes. "The microscopic diagnosis of LVI is challenging which highlights the importance of excellent pathologists," says Lubbe, who will present the results this week at the Annual Meeting of the American Society for Radiation Oncology.
Knowing that the disease is going to extend to neighboring lymph nodes, such as those in the armpit, is important prognostically. But it has still been unclear whether supplementary radiation therapy targeting these areas improves outcomes.
"There still is a lot of debate as to whether additional radiation to the regional lymph nodes is needed in a woman with LVI," Lubbe says.
In the study, Lubbe's team analyzed an extensive database of 3,082 breast cancer patients who underwent whole-breast radiation or minimal surgical resection of breast tissue between 1970 and 2009. This dataset, at least twice as large as many others of its kind, provided enough statistical power for the investigators to detect a subtle, yet significant trend.
"Luckily, at Fox Chase, we had the resources to maintain this huge database by meticulously following a large number of patients over the course of decades," Lubbe says.
The team searched for factors aside from LVI that determine outcomes. The disease was more likely to invade lymph nodes in women younger than 35. Also, additional radiation therapy under the armpit via a technique called a posterior axillary boost (PAB) lead to fewer breast cancer recurrences in these women's regional lymph nodes. Ironically, this extra procedure led to less regional recurrence even though the women were of higher risk than other treatment groups. Overall, the 10-year recurrence rate was only 1.4%. But it was 4% for women treated with radiation above the collar bone alone, compared to 0.5% for those who also received a PAB - the posterior boost of radiation under the armpits.
"Our data suggest that patients who are at higher risk of their cancer spreading can potentially benefit from additional radiation by a technique called a posterior axillary boost," Lubbe says. "But the recommendation to add radiation, and what technique is used, is very patient-specific, because with any intervention there's additional risk."
In the future, Lubbe would like to identify other objective biological markers, such as proteins or genes, which predict recurrence rates and patient outcomes. "Ultimately, we'd like to find a faster and more accurate process for assessing the risk of cancer spread to regional lymph nodes and the rest of the body," Lubbe says.
Source: Fox Chase Cancer Center
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Soooo glad to see this thread. I too have LVI but also have angiolymphatic invasion. Oncotype score of 19. Onc insisted no chemo. I wish I was as educated at diagnosis as I am now, I think I would have insisted on chemo, as dreadful as it is. I have read and read and read about both LVI and angiolymphatic invasion and feel like there is no consensus out there. Mostly what I have read is that LVI leads to a poorer prognosis. But, like everyone here says, each person and their cancer are unique. Would love to hear more input.
All the best, Tracye
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It is my understanding that Lymphovascular and Angiolymphatic invasion are the same thing.
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Very interesting thread. So I have a question for anyone who knows....what happens if your pathology report says nothing about LVI - does it mean that none was detected?
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I believe that means none was seen.
But I'm not sure...
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I saw three med onc's and none believed in doing scans because I was stage one despite LVI. I saw one at University of Michigan, one at another prominant hospital in Detroit area and another at Northwestern here in Chicago after our move. They all say "we don't scan people that are stage 1". I find that rediculous considering there was LVI. That freaked me out the most. None of the doctors I saw even mentioned that on my path report - I read it myself and questioned them about it. I hate that there is so little information about it.
The article above is interesting.....but I guess my question about radiation is did they also mean they would suggest radiation on BMX patients too? I had a BMX and no rads but did chemo. THe LVI is what made me decide on the chemo. I hate to think that I am at risk of a "poorer prognosis" and no one would do anything about that and watch me more closely.
The hard part is U of M and Northwestern are well regarded in terms of cancer treatments....
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Hi Ladies,
I wish the cancer researchers would read this thread and start doing more LVI research. I had IDC/LCIS/DCIS with LVI, node negative. After two surgeries with close margins, I chose BMX. But, my surgeon was not advocating PET or bone scans since I was stage 1. So you know what I did? I went back to the first surgical consult, who had recommended Pet and bone scan and I used his prescription to do the tests and I had them sent to all the new docs. We have to be assertive, more assertive than the docs I think. It did give me peace of mind to do the tests, but I am still considering chemo, even with a very low onco score. Also, the original path slide sent to Genomic did not have the LVI in it, so my onc redid the test and used the slide with the LVI--we are still waiting for results-VickyB
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I had bilateral BC. When I was making my "RADs"decision, RADs was recommended to me because of LVI despite my BMX. This was in my breast with negative nodes & LVI. I did get RADs on the other side because of positive nodes. What I read at the time, was that RADs would decrease regional/local reoccurences with LVI. Lots of discussion on these boards at the time about this, as well as data/studies emerging. I agreed to the RADs on my LVI side.
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Hi,
I also had lvi ( found cancer cells in artery etc), when they did my snb they clipped some large arteries and blood vessels around the tumour, I had neo adj chemo then mastectomy followed by rads.
I was also node neg but had skin involvement because of this they did the rads. They also did ct and bone scans as part of the initial diagnostics scans. I too have always been confused as to why they never really mention lvi but it did form a big part in the decision of my treatment plan.
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I have 'extensive vascular invasion'. I have only 'met' one other on this board with this diagnosis.
It scares me to death, but, my Drs assure me that it 'ISN'T IMPORTANT'.... wtf !! of course it's important. One Onc I really pressed explained to me that as the vascular invasion was found next to the tumour, THERE IT WOULD STAY. It was found sitting there, in the veins in my breast, but wouldn't go anywhere, it was 'contained'....wow, must be magic. This is what we have to put up with in UK.
I didn't do chemo, I had no idea at all that I should have done, I was told it wasn't necessary, at that time I understood not a thing about bc, and was told by the Drs and breast care nurses to stop going on the Internet 'scaring myself'
Isabella.
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Hi, new here on the board. Just had BMX done last week, nodes negative, grade 2. My surgeon didn't even mention LVI in our post op appointment, but here it is staring at me on the pathology report. Meeting onco in 2 weeks. This is the first I've heard of this and have been looking around for information about it. Seems pretty significant to me, and here I thought if I got clean nodes I'd walk away with just tamoxifin.
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I agree with you that there is a HUGE lack of emphasis on LVI. I was diagnosed in July, had lumpectomy in Aug (and the path report said LVI in the IDC tumor but my surgeon never mentioned it), had re-excision in Sep, and decided on BMX in Nov. Only at my post-op lumpectomy appt with surgeon did he advise me to go to an oncologist. My onco came in very low, and my onc has suggested lupron injections with tamox as an aggressive option (but she would give me chemo if I really insisted). She said the LVI means that they can never really guarantee that one or more of those cancer cells did not circulate elsewhere into my body. So she did tumor marker blood tests, did a liver MRI, and we are watching for signs of mets. FYI, the surgeon who did the onco test did not submit a slide with the LVI. So my onc requested a new onco test, this time with the LVI present on the slide. We want to see if this makes a difference in the score. For some reason Genomic does not include LVI as a separate prognostic indicator with their scoring system, which is a flaw. I think this site should have a thread on LVI. It is not actually mets, or positive nodes, but it is an important finding in a path report.
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I also had extensive lymphovascular invasion. I was node positive and had chemo. I couldn't have radiation because I had my "maximum lifetime dose" 18 years ago. I am on tamoxifen now. LVI does frighten me but so far, no new cancers have been suspected following scans.
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I got a copy of oncologist's consultation by mistake and the #1 diagnosis at end of report said "extensive lymphovascular invasion." I assumed that wasn't good, so started googling, etc. I knew after all my research on Her2+ and LVI that I needed chemo. She, initially, was going to do an ONCO dx test, but thank God, my insurance would not recognize the test in lieu of being Her2+. I still don't know what she was thinking by even wanting to do an ONCO dx test since I had lymph node involvement.
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I, too, had LVI following my dx in 2008. I didn't understand the repercussions then and worried myself sick about them. Here I am nearly 4 years out and not worried at all. IF it comes back......I'll deal with it........ but, in the meantime, I'll just enjoy life.
Mal
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Dunno how rare it is, but it was one of the five "don't collect $200 and go straight to chemo" criteria at my hospital. I had a haunting case: localized LVI on biopsy, none on final pathology. I wonder which to believe...I had chemo regardless, as I was grade 3.
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This makes me wonder about pathology showing LVI after surgery and NOT at biopsy. When they are basically "stabbing" at the tumor during biopsy.....can't that in itself cause some cancer cells to escape??
I remember my BS telling us how they use a completely different set of tools in the operating room on the BC side and the Prophy side for my BMX. So if they are cautious enough to want to switch operating tools... why wouldn't there be some risk of invasion imposed at the time of biopsy?
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Very good point, Susan.
Isabella.
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I had these same thought more than once, but did not do much reading on it as it did not apply to me personally. You would think any level of invasion is not too good when it is cancer we are talking about. Last I heard, cancer was kind of unpredictable and it seems shocking that the docs don't seemed concerned when there is just a "little bit" of LVI.
I can only guess that there are enough cases of LVI that don't lead to mets, that the risk of doing chemo might outweigh the benefits? Welcome to yet another "gray area" in trying to decide on treatment options.
p.s. The rads option, to radiate nodes with micromets or where some LVI is present...well, will that end up giving you lymphaedema? Choices, choices?
Susan, that is my major reason that I did rads and Tamox. To "clean up" the area after it got disturbed by surgery and the biiopsy too. I really have no idea what circulated away from the site, do I?
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elimar....didn't you know...NOTHING will circulate away from the site !!!!!!!!!!!!!!!!!!!!!!!!!!! well, that was the story I was told, anyway !!
Isabella.
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