Pathology and Other Reports - Would Like Some Opinions

They would indeed have tested for HER2, but the result takes a few weeks to come back.

Hi Decision:

I agree with SpecialK's remarks.

You noted: "The pathologist found no malignancy in the tissue sample itself with no tumors, and the radiologist recommended another mammogram in six months based on imaging performed after the surgery, if I interpret the time stamp correctly. The time stamp between the first images and the second images done by the radiologist indicates a two hour interval in between. The surgeon was on the OR floor for two hour removing breast tissue. The pathologist reported that the tumor is early stage or stage 0. I am not sure what all of the initials in the tumor stage description stand for."

Tumor Stage: pTisNX

The "p" stands for pathological.

"Tis" means "carcinoma in situ".

Nodes (N) have not been assessed (that's fine with pure DCIS so far)

https://cancerstaging.org/references-tools/quickre...

I am assuming the 9/14/2015 procedure ("excisional needle biopsy" or "needle-directed biopsy") was an excisional surgical biopsy (essentially a "lumpectomy"), in which "Needle-wire localization" was used to flag the area for surgical removal.

The surgical pathology report controls your diagnosis. While imaging studies can identify areas of possible suspicion, the actual diagnosis of "breast cancer" rests on pathology. The MRI findings do not negate surgical pathology findings of an area of DCIS at least 1 cm in greatest dimension.

Imaging may also be performed on tissue samples removed by stereotactic core-needle biopsy or from surgical biopsy, to check for the presence of calcifications. This is to confirm that suspicious calcifications have been successfully sampled or removed. Imaging studies of biopsy tissue are not used to diagnose cancer, nor can they exclude the presence of cancer.

So, I agree with Brookside that a six-month follow-up recommendation is likely a separate question, and is in addition to any treatments you should receive for the DCIS identified by biopsy. This does not mean that you can/should wait six months for a further surgical procedure. As SpecialK noted, re-excision to obtain clear margins, when indicated, is usually done shortly after the last surgical procedure (assuming it is not contrindicated by some other health status concern). You can confirm that with your providers.

The pathology report indicates the presence of at least 1 cm of "Ductal Carcinoma In Situ (DCIS)". This is a diagnosis of "breast cancer." Pure DCIS would be "Stage 0" breast cancer, which is confined to the ducts ("non-invasive").

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC358089...

The pathology report also includes an evaluation of margins by the pathologist:

"Evaluation of Margins: DCIS extends close to (0.05 mm or less) and is likely focally at an inked and cauterized tissue edge in sections examined"

Whatever this means, it goes to the question of whether the observed margins are "negative", "close", or "positive". The adequacy of margins is within the surgeon's expertise. Your surgeon seems to have interpreted the pathology findings as indicative of a further surgical procedure, likely a re-excision, to attempt to obtain better margins. The definition of clear margins is not without controversy, and final margin status may affect risk of recurrence and decisions regarding radiation.

The majority of DCIS patients elect to treat DCIS with surgery at a minimum:

(a) Lumpectomy with or without radiation

Entails surgical excision (by excisional biopsy or lumpectomy);

May entail possible re-excision(s) to obtain clear margins;

If disease is very extensive, may lead to mastectomy;

(b) Mastectomy, most commonly without radiation

Many patients with DCIS can be treated by mastectomy alone, and this is one factor behind this choice. In limited cases, findings from the surgical pathology or sentinel node biopsy may lead to the recommendation of radiation.

The National Comprehensive Cancer Center (NCCN) provides guidelines for breast cancer treatment (Version 3_2015, available at NCCN.org). As stated in the NCCN guidelines re the primary treatment of ductal carcinoma in situ:

"For the vast majority of patients with limited disease where negative margins are achieved with the initial excision or with re-excision, lumpectomy or total mastectomy are appropriate treatment options. Although mastectomy provides maximum local control, the long-term, cause-specific survival with mastectomy appears to be equivalent to that with excision and whole breast irradiation."

Please do not delay, and ask for an appointment with your surgeon to review the surgical pathology report, the status/adequacy of the margins, your surgical options, and the surgeon's recommendation and basis for same. Be sure to ask about what would happen if clean margins are not achieved by re-excision, so you know.

When unsure, many patients also seek a second opinion regarding one or more of their imaging, pathology, surgical and post-surgical treatment options.

BarredOwl

Thanks for correcting me on the HER2 issue, Special K.

DecisionFreak, I just clicked on the first link I mentioned earlier, and found this regarding biopsies, excisional and otherwise,

"Biopsies are done only to make the diagnosis. If DCIS is diagnosed, more surgery is needed to ensure all of the cancer is removed along with "clear margins," which means that a border of healthy tissue around the cancer is also removed. Usually this means having lumpectomy, or in some cases (a large area of DCIS, for example), mastectomy."

There is, of course, lots more information on that page, but it does indicate that, once DCIS is diagnosed, a follow-up surgery is the norm. Because your pathologist does indicate that your tumor was properly inked (a different standardized color on each aspect of the lump), the surgeon will easily identify the areas where more tissue needs to be removed.

Like April, I agree with Barred Owl's next steps recommendation.

Hi:

I am not sure I agree with BLinthedesert's first two paragraphs. This is my understanding (as a layperson):

Procedure 1 (08/11/15): A stereotactic core-needle biopsy removed tiny amounts of tissue.

The pathology found ADH, with concern for DCIS. Therefore, Procedure 2 was recommended.

Procedure 2 (09/14/15): An "excisional biopsy", also referred to as a "lumpectomy", was performed.

Procedure 2 removed a rather large chunk of tissue ("breast tissue weighing 21 gram in aggregrate and measuring 5 x 3 x 1 cm, 2.5 x 2.5 x 1 cm, 3 x 2.5 x 1 cm"). Among other things, the pathology on this material found "Ductal Carcinoma In Situ (DCIS)" about one centimeter in greatest dimension.

Thus, according to the dated pathology report text above, Procedure 2 (the lumpectomy) found the "Ductal Carcinoma In Situ (DCIS)" which was "[a]pproximately 1 centimeter in greatest dimension."

Then, to recap along the lines of my post above:

The current diagnosis from the lumpectomy is ER+PR+ DCIS, which is a malignant breast cancer per the pathology report:

Histologic Type: Ductal Carcinoma In Situ (DCIS)

Histologic Grade: Low grade (grade 1 of 3)

Size/Extent of DCIS: Approximately 1 centimeter in greatest dimension

Tumor Stage: pTisNX

Final Result: Malignant

While no invasive disease (e.g., IDC) was found so far (good), an area of DCIS was found in Procedure 2. DCIS is malignant breast cancer. The question is, has it been sufficiently removed by the Procedure 2 lumpectomy or not? Given the margins, a further surgery such as a re-excision may be indicated in the short-term. Consultation with the surgeon and/or any second opinion should be attended to now, not within six months. This might include, for example, a second opinion to confirm the diagnosis of DCIS, if desired.

Wholly independent of the question of additional surgery (e.g., re-excision) and possible further treatment of the DCIS, there is a separate and additional recommendation for six-month follow-up mammography. None of the imaging described can either diagnose or exclude the diagnosis of breast cancer. The diagnosis of breast cancer rests on the pathology.

This is my view as a layperson.

BarredOwl

Hi BL:

I had to read it over several times, to separate out Decision's impressions of what was found (which seem to contain some misunderstandings). And as you note, a less common terminology was used to describe Procedure 2 (lumpectomy), focusing on the needle rather than the guide-wire placed. Hence my comment, "I am assuming the 9/14/2015 procedure ("excisional needle biopsy" or "needle-directed biopsy") was an excisional surgical biopsy (essentially a "lumpectomy"), in which "Needle-wire localization" was used to flag the area for surgical removal."

We all agree on the need to seek professional advice now!

BarredOwl

DecisionFreak, I just have to tell you how very much you remind me of myself. In the face of medical shock, frustration, confusion, and downright mystery, I go directly to detail, to research, to clarity. It sure sounds as though this process has worked for you. From all your sources, you have wrestled through the foreign and cryptic language of your pathology report, and come to a confident understanding of where you are and are not.

From my point of view, the communication from your surgeon was faulty from the beginning. Your initial diagnosis was benign and your excisional biopsy was designed to remove the presumed-harmless lesion for diagnosis, not to produce the wide borders normal for a known-to-be-malignant lesion. As part of your pre-op, the office (doc, nurse, PA, handouts, etc.) should have prepared you for the possiblity of a second surgery, and I won't even address their follow-up bedside manner.

Yes, you want a surgical follow-up, and yes, you want to get rid of any DCIS that's hanging out on the edges of your incision, and yes, with DCIS, there is no need for urgency. And yes, you have all the right next moves lined up. Please do not forget to keep us in the loop!

I am also glad to read your update. You seem spot-on in all ways. Your research, questioning, and decisions all seem very sound to me. Please keep us posted. - P.

The left breast was diagnosed with dcis high grade necrosis focally present and micro invasion negative. I decided to have a double mastectomy and I was able to have direct implants. My mastectomy was 9-2-16 and today 9-15-16 I saw y oncologist to discuss sentinel node pathology which was removed during the mastectomy. I am so full of anxiety that I can't think straight. My after surgery path report showed that I had isolated tumor cells <200 cells one size of largest metatastic deposit (if any) cluster of ten cells ancillary studies still pending. In comments section it states isolated tumor cells were identified within the sentinel lymph node. However, despite additional sampling of the left breast immunohistochemical stains performed in an attempt to locate a micro invasion focus none was identified. My onc is sending for another reading and also taking it to a tumor board for discussion. He did tell me that I would be on arimidex and he also mentioned radiation. My concern is what about the implant? Radiation would be on the anxilary node. Has anyone else experienced this issue?