Do most with Grade 3 DCIS also have...?

chocomousse · June 2015

Does anyone know what the liklihood is that someone with Grade 3 DCIS with comedonecrosis cells will also have node involvement? Anyone with this diagnosis have zero node involvement?

SpecialK · June 2015

Without an invasive component your DCIS would be confined to the duct, so not able to spread to the nodes. If there were a microinvasion, or larger invasive aspect, you could then have nodal involvement.

Annette47 · June 2015

SpecialK is correct - without at least a micro-invasion, you would not be able to have node involvement no matter what the grade of the DCIS. If I remember correctly the chance of a micro-invasion is approximately 20%, and my surgeon said that with a micro-invasion the chance of node involvement is only 5-10%, so your overall chance would be .20*.10 so about a 2% chance (using the 10% number which she felt was on the high side).

And while my DCIS was considered Grade 2, there was comedo necrosis, I did have a micro-invasion and my nodes were clear.

chocomousse · June 2015

Thanks guys.

I guess what I was asking is what are the chances that someone with DCIS Grade 3 would also have invasive cells in their nodes. If that chance is only 5-10%, would it be prudent to refuse a SNB during a lumpectomy?

ballet12 · June 2015

The chance of positive nodes with pure DCIS, grade three, is virtually nil (which is a lot less than 5 to 10 percent), unless they somehow missed a microinvasion. It is not standard practice to do snb with lumpectomy for DCIS, only if microinvasion was found. Did you have a microinvasion in the core biopsy?

ksusan · June 2015

I read and was told that SNB was standard for grade 3. My SLNs were clear on the DCIS 3 with necrosis side.

MotherofFour · June 2015

I had grade 3/comedo necrosis and had zero involvement for 2 sentinel nodes and 1 other node. But they measured .2 mm from the chest wall.

MotherofFour · June 2015

Yes, SNB is standard for grade3. I also had a mastectomy.

Jelson · June 2015

I had Grade 3 DCIS - my treatment was lumpectomy- no SNB and radiation - though there is debate about the necessity for radiation after DCIS+ lumpectomy in some circumstances when the DCIS is low grade - there doesn't - seem to be any debate when it comes to DCIS grade 3. With regards to SNBs - the norm seems to be that it is offered when the treatment choice is mastectomy for DCIS and the rationale is that once the mastectomy is performed, there will not be another opportunity to trace the sentinal node - which might be desired if upon biopsy, the mastectomy tissue in that breast reveals unanticipated IDC. Please note that ksusan had a bilateral mastectomy - I hope you are recovering well, ksusan!

trailrose · June 2015

I had 0 out 3 nodes negative. My BS said since it was Grade 3 DCIS with comedonecrosis that with a MX SNB is the standard. When I was first diagnosed he recommended LX w/ radiation but said nothing about SNB. Right before I was wheeled to the OR for my BMX I asked him the chances of the nodes being positive and he said 5 % to 10%. Of course I had to wait on my final path report after the surgery to say whether or not I had an invasive component. And what a long 3 days that was! I cried my eyes out when they called to let me know it was pure DCIS.

angmom41 · June 2015

Hi chocomousse, I'm sorry you are facing this diagnosis. In January, I was told that I had over 5cm of high grade DCIS in my left breast. My only option was MX. My needle biopsy of 2 different areas showed microinvasion in one of those areas, and I was told that my chances of finding invasive cancer was about 30% and node involement less than 10%. My final pathology revealed two areas of IDC, luckily both were very small, just big enough to be considered IDC and not microinvasion. I had no node involvement.

I wish you luck and send you strength to make these decisions and start the process of healing!

Annette47 · June 2015

I think part of the confusion depends on the type of surgery. Because there is a higher chance of micro-invasion with Grade 3, it is standard practice to do a SNB with a mastectomy because once the mastectomy has been done it is no longer possible to identify the sentinel node. In other words if something is found, you would not be able to then go back and do an SNB. With a lumpectomy however, you can always go back and do an SNB later if something is found, so even with Grade 3, it is not necessary to do it at the time of the lumpectomy like it would be with a mastectomy.

chocomousse · June 2015

Thank you everyone!

Thanks Angmom41!

I was told the same thing as Ksusan regarding a lumpectomy for DCIS. A SNB is standard when the grade is high and the cell type is highly active.

@Ballet12, no. My core biopsy revealed zero invasive cells but my radiologist noted in my records that based on certain features of the lump, he thinks invasive cells are present.

It's encouraging to hear that everyone had negative nodes, even when microinvasion was present.

I have asked my BS through his nurse if we could avoid a preemptive SNB and instead base it on the results of the post LX path. report.

Jelson · June 2015

Chocomousse - here are the NCCN guidelines for DCIS it really seems that SNB is NOT normally done for DCIS lumpectomy

patient version - http://www.nccn.org/patients/guidelines/stage_0_br... (on about page 28)

practitioner version - http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf (footnote h under DCIS)

MizMimi · June 2015

I was told they did not think I had any node involvement due to the DCIS being confined to the duct. I have not had my surgery yet... will be in mid-July most likely. I am opting for DBL MX.

chocomousse · June 2015

Thank you Jelson. Although SNB is only mentioned in reference to a mastectomy, I didn't see it expressly stated that it is not recommended during a lumpectomy.

My husband wants me to have a MX due to calcification specks in other areas of my breast. The first 2 BS's thought they may be early DCIS and wanted to remove these along with the 4cm lump which would entail a MX. The last BS, who'll be doing my LX, didn't comment on them at all. Upon further reading, it seems that these can be zapped during radiation treatment (if I choose to have it).

I haven't heard back from his nurse yet re foregoing the SNB. My surgery is scheduled for this month.

Sultana · June 2015

It seems I am an anomaly, I had DCIS, high grade with comedonecrosis. I had a lumpectomy and SNB and there it was, positive in one node, they took another 11 and all were clear. I have just finished 12 weeks of Taxol and I have an appointment with MO this week to discuss further treatment. Even after surgery there is no indication of it coming from the DCIS in the breast, but must have got their somehow. Everyone is mystified as to where it has come from.

chocomousse · June 2015

Thanks for sharing that Sultana. One of the BS's told me that a small number of invasive cells could be hiding in one sentinel node but absent in the others which is why she insisted on removing a minimum of 2-3 nodes instead of just one. Were you given the option of radiation treatment over an axillary biopsy or were they all removed while you were under? I was told that if invasive cells were found in the SNB, the remaining nodes could be treated with radiation rather than removed.

Sultana · June 2015

The sentinel node was checked while I was under and when found positive the auxiliary nodes then removed. Then the taxol, because the amount of cells were small my MO is getting a second opinion before deciding on my next course of treatment, she doesn't want to give AC if it is not necessary. I did have my oncotype sent for testing, but they were unable to do it because there was no tumor (I assume not enough cells in the node, I know they had two attempts at it). I will follow upwith radiotherapy and then hormonal therapy as I am ER+ PR+ HER2-

ballet12 · June 2015

Hi Chocomousse, did they give you the option of doing the snb after the pathology results are available from the lumpectomy? It is possible to do snb after the fact with lumpectomy, but not with mastectomy. I did also read the NCCN guidelines, and without doing additional research, it doesn't say that snb is not done with lumpectomy, but I believe standard practice doesn't recommend it, unless one has microinvasion with the core biopsy. It used to be a more common practice with pure DCIS. Of course, you know that there is a risk of lymphedema with snb. It's actually one of the reasons that I didn't do mastectomy (with 5 cm plus of multifocal DCIS and three previous surgeries on that breast). It's not the only reason, but it did weigh heavily. And yes, radiation is supposed to treat any stray cancer in the breast, although it doesn't reduce the recurrence risk to 1 or 2 percent. Depending on an individual's history it could be around 12-15 percent (or less), which is unacceptable to some people (then there's the hormonal treatment if chosen). Did you have an MRI? Sometimes those additional areas of calcifications are biopsied to help determine if mastectomy is necessary. At the same time, if you are concerned with cosmetic deformity, then mx is the way to go, and the snb is done pretty much automatically.

ballet12 · June 2015

Also, I don't think that "grade" of DCIS enters into whether they do snb with mastectomy. They seem to do it with all grades of DCIS, because they can't go back and do it later, if they find invasive breast cancer on the mastectomy pathology. They can only do anxillary node dissection after the fact, which is much more invasive.

middleagedmama · June 2015

chocomousse,

I had a nipple and skin sparring double mastectomy with sentinel node biopsy. They took 6 nodes and all were negative. Like you I had the choice of lumpectomy with radiation and because I was ER and PR + I would have to go on tamoxifen. For me I wanted to only go through this once and have the least amount of chance of it returning. Because I had the double mastectomy and there were no surprises I didn't Have to get any other treatment. I am almost at the end of my tissue expansion and then I will have my exchange to implants. I do not have any regrets

chocomousse · June 2015

Hi guys!

Have those of you who have had their nodes removed experienced lymphedema?

Well, I canceled my surgery appt. and had a 2nd meeting with my BS. He said I could refuse anything I wanted so if I didn't want a SNB with the lumpectomy he wouldn't do it. I'm surprised at how accomodating he is. Anyway, he looked at my images again as my husband was concerned about 2 other clusters, which I don't think he noticed the first time because his nurse wasn't able to enlarge the images, and felt like those would need to be removed too so long story short, I'm going to have a mastectomy. This way I can avoid future surgeries to get better margins or remove additional clusters and I won't have to worry about radiation therapy. I was concerned about the length of MX surgery, being on a vent and the recovery time which he eased by telling me that basically, due to his surgical expertise, he could do a simple MX in 45 minutes. He said the recovery time would be about the same. He said that he would need to do an SNB with the MX. My question is now, can't a MRI or PET scan detect invasive cells in the lymph system? An SNB can't be the only way doctors can determine this.

I also asked him if it would be ok if I put off the MX for another 2 months and he said yes. I was told that DCIS is slow growing but now I'm second guessing myself. If there are invasive cells involved, could they spread to my lymph system within that time?

SpecialK · June 2015

chocomousse - the reason for not insisting on a SNB with lumpectomy is that breast tissue remains after lumpectomy so SNB can actually be done at a later point, you can't do a SNB after mastectomy so that is why most docs are more likely to want one. Once the breast tissue is gone you can't locate the sentinel, and if an invasive component is found post-operatively without doing a SNB, the opportunity is lost. PET or MRI can only detect things of a certain size - definitely not cells, LVI, microinvasion or micromets - these are the things that show up in a SNB.

Stephmoen · June 2015

I had a biospy done it came back as DCIS and IDC the size was 1.5cm..due to my pathology report being her2 positive chemo was suggested first for me so I can use the new drug perjeta which I am thankful for. I had a pet scan done prior to chemo showing no lymph or organ involvement this calmed my nerves a lot but like Special K said there could still be micromets that they didn't see.. With my pet scan results I noticed my maximum suv was at 1.9 with my breast cancer that's really low! They don't consider anything over 3 cancerous I asked my MO about it yesterday and she said it is very low and she believes my cancer is mostly made of DCIS and the invasive area is small but we will never know for absolutely sure because I did not have surgery first. I'm a little upset about that I would love to know most if my cancer is not invasive but I know it was meant for my pathology to find that invasive component being 30 and having cancer I want every treatment possible to keep me here for my 2 kids! I have 4th infusion of TCHP today my lump has shrunk a lot can feel a very very small amount left my dr said at surgery some DCISmaybe left since it doesn't respond to chemo as much I'm ok with that but I'm hoping for a PCR at the time of my mastectomy they will also do a SNB I would like them to at least take 3 out I'm not sure what the protocol is for my BS I want absolutely nothing left behind!

Do most with Grade 3 DCIS also have...?

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