confused over second pathology report

JuniperCat
JuniperCat Member Posts: 658
edited March 2016 in DCIS (Ductal Carcinoma In Situ)

Hello! I am new to blogs and forums so please forgive me if I have gone overboard with how much information that I am providing. I am wondering if you can offer some insight into my personal situation. This September I had my yearly mammogram (I'm 58), which showed something suspicious. I had a core biopsy that revealed a small (1.5cm) invasive ductal carcinoma, which required a lumpectomy. I had the lumpectomy done last month (Nov. 11th). The pathology report showed the following:

"The lumpectomy contains both invasive duct carcinoma and associated multifocal high grade ductal carcinoma in situ (DCIS) near the prior biopsy site. Additonal foci of DCIS are also present away from invasive tumor and one such focus of DCIS involves the lateral margin of the lumpectomy. The additional anterior medial margin also contains focal DCIS which is <1 mm away from the final margin. The sentinel nodes are negative for metastatic carcinoma. Prior studies on the diagnostic needle biopsies showed the invasive tumor to be ER+/PR+/HER-2 negative."

This report prompted my surgeon (whom I like and trust) to suggest that I do a re-excision to remove the DCIS. I had this done last week (Dec. 1st). The results of this second surgery are online via the hospital's patient portal. I copied them; they are:

" FINAL DIAGNOSIS A. LEFT BREAST, 1 O'CLOCK, ADDITIONAL LATERAL MARGIN, re-EXCISION: - RESIDUAL 3 MM FOCUS OF HIGH GRADE DUCTAL CARCINOMA IN SITU PRESENT. DCIS TUMOR EXTENDS TO THE FINAL RESECTION MARGIN. NO INVASIVE CARCINOMA IS RECOGNIZED; BIOPSY SITE CHANGES; see comment B. LEFT BREAST, 1 O'CLOCK, ANTERIOR MEDIAL MARGIN, re-EXCISION: - NEGATIVE FOR IN SITU OR INVASIVE DUCTAL CARCINOMA; BIOPSY SITE CHANGES. Diagnosis Comments :The prior left breast lumpectomy at 1 - 2 o'clock (11/11/15) with high grade in-situ and infiltrating duct carcinoma is noted. In that lumpectomy the high grade DCIS involved the final lateral margin and was close to the final antero-medial margin. On these re-excision specimens, a residual 1-2 mm focus of DCIS is present within the additional lateral margin and extends to the final margin. An immunostain for smooth muscle myosin (SMM) shows attenuated myoepithelial cells within the DCIS, precluding invasive carcinoma. A CD34 immunostain which is normally immunoreactive in endothelial cells lining blood vessels and lymphatic channels was also performed and excludes tumor within lymphatics." Sorry...the capital letters aren't mine...they were in the report that I copied

Again, I'm sorry if I've provided an overwhelming amount of these specifics here, but I'm not sure what to make of the pathology from the second surgery other than a very small amount of DCIS still remains in my breast. Can you please kindly tell me what you think that most professionals would recommend in this situation? I do have an appointment with my surgeon this coming Thursday and I'm petrified that she'll recommend a mastectomy, which I really don't want to do considering the amount of DCIS is so small. Any thoughts, suggestions, comments that you may have to offer would be gratefully welcomed. Many thanks!!!

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  • 123JustMe
    123JustMe Member Posts: 385
    edited May 2016

    bump

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    ummm...can you please elaborate?

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  • Jelson
    Jelson Member Posts: 1,535
    edited December 2015

    I don't think you provided too much info for a BCO post. The bad news is that you have a positive margin but congratulations - the good news is that what little remains is DCIS. I am betting that the surgeon would be comfortable going either way, guided by YOU. Because your tumor did have IDC, your surgeon may be talking to you about radiation and possibly an oncotype dx test to see whether chemo would be beneficial. Good luck to you on Thursday!

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    Many thanks, Jelson, for taking the time to respond to my post. I'm curious as to how residual grade 3 DCIS (even though tiny amount is left) will be regarded by my surgeon. Will radiation generally destroy this? Be well!!

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  • ballet12
    ballet12 Member Posts: 981
    edited December 2015

    I had three surgeries to get clean margins for DCIS. I also didn't want a mastectomy. You might want to get an MRI to help determine if the DCIS is even more extensive, prior to a third lumpectomy, which would help make the decision.

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  • ChiSandy
    ChiSandy Member Posts: 12,133
    edited December 2015

    The other good news is that the second biopsy seems to say you also had no lymphovascular invasion. And what was found in the margins was not IDC but DCIS. My guess is that the surgeon would probably give you the option of mastectomy, re-re-excision+radiation, or radiation and thereafter followup imaging to ascertain whether the DCIS has spread w/in the duct or become IDC. And if your surgeon or oncologist doesn’t order an Oncotype DX, you should ask for one. The report you provided didn’t indicate the grade (1, 2, or 3) of the original IDC tumor. Perhaps if it was a Grade 3 (and likely the DCIS too--“high grade” usually refers to Grade 3), that may be the reason the test was not ordered. A 1.5cm IDC, if Grade 1 or 2, would likely have put you into the “gray area” of chemo vs. no chemo for which Oncotype DX was developed.

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    Dear Ballet12,

    I'm pleased to hear that your margins are clean! My surgeon doesn't like to use MRI because of too many false positives associated with that type of imaging. It seems worth it to have the third surgery to get rid of the DCIS. Many thanks for your reply to my post

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    Dear ChiSandy,

    Thank you so much for taking the time to read my post and for your informative reply. Why is the Oncotype DX not appropriate for grade 3 DCIS? Thank you!! Be well

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  • Jelson
    Jelson Member Posts: 1,535
    edited December 2015

    Here is the BCO explanation of the Oncotype Dx test for IDC, grade isn't mentioned as a factor.

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    Jelson, can you please re-send the link?

    Thank you!

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  • muska
    muska Member Posts: 1,195
    edited December 2015

    Hi JuniperCat, your DCIS was multi-focal, if I understand correctIy there were several foci in the tissue that was taken out. I would ask the surgeon how (s)he can be sure there is no more DCIS in the parts of the breasts that were not touched. I would also go for a second opinion - no matter what the first surgeon says - and consult with a medical oncologist on the rest of the treatment plan. Type of surgery - lumpectomy or mastectomy - may matter for subsequent treatment decisions, e.g. whether to have radiation or not.

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    Dear Muska,

    Thank you so much for responding to my post. I haven't seen an oncologist yet but probably will have to soon. How can they know if there is any DCIS in the rest of the breast if it is microscopic? I think that was why my margins weren't clear. When you suggest getting a second opinion, do you mean should I see another surgeon? Thank you again for your help

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  • muska
    muska Member Posts: 1,195
    edited December 2015

    Yes, I would probably get a second surgical opinion and certainly talk to a medical oncologist and radiation oncologist if needed before making further decisions. If you can avoid radiation by having a mastectomy I would consider mastectomy. You would have to radiate the left side and the risk to heart would be higher.

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  • ballet12
    ballet12 Member Posts: 981
    edited December 2015

    They can't actually be sure they got all of the microscopic DCIS cells. That's why radiation is very important, which you would absolutely be getting with the IDC anyway.

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    thank you so much for your suggestions and your help!

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    I've just deleted the post because you've all been tremendously helpful. I will most likely end up getting a second opinion, thank you again!!

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  • Jelson
    Jelson Member Posts: 1,535
    edited December 2015

    JuniperCat - sorry if I forgot to post the webpage http://www.breastcancer.org/symptoms/testing/types/oncotype_dx I got to this via the breastcancer.org home page - which provides a marvelous factual and easy to understand and navigate road map for all things breast cancer.

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    thank you so much!

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  • ChiSandy
    ChiSandy Member Posts: 12,133
    edited December 2015

    Oncotype DX is available for DCIS (it’s a different score scale) but is not yet “standard of care” the way it is for early stage, hormone-positive, HER2-negative nonaggressive (Grade 1 or 2) IDC. Its main predictive value is for the probable effectiveness vs. risks of chemo--and a Grade 3 tumor, since its cells grow faster, is likelier to respond to cytotoxic chemo than are the slower-growing 1 and 2. (Chemo drugs target rapidly-dividing cells, which is why mucous membranes, bone marrow, fingernail beds and hair follicles--among the fastest-dividing in the body--are "collateral damage" in chemo).

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  • JuniperCat
    JuniperCat Member Posts: 658
    edited March 2016

    Dear ChiSandy,

    Thank you for the info. I will ask the surgeon about it tomorrow when I see her. I'm not sure if I'll be eligible for it. Be well!!

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