IDC with lobular features - anyone get this DX?

mellee · February 2017

I recently noticed, buried in my path report, that my tumor was described as "Invasive ductal carcinoma with lobular features" (IDC-L). However, none of the MOs or ROs I consulted with (or my BS) said anything about it.

I've done a bit of research on it, and I know it's not considered a separate diagnosis from IDC. However, some researchers believe it is a distinct variation on IDC that behaves more like ILC. Specifically, when compared to IDC, IDC-L tends to have more favorable pathology (low grade, strongly hormone positive, less likely to overexpress Her2) but a higher rate of nodal metastasis (51% vs 35%). It also has a higher rate of second primary breast cancers, but a lower rate of metastatic spread.

Anyone know anything about this? I'm wondering if I should factor it into my radiation decision.

Here is a report on it, as well as a link to the full study:

Mixed Ductal/Lobular Carcinoma May Be Unique IDC Variant: http://www.medscape.com/viewarticle/774485?pa=0dG9...

Invasive ductal carcinoma with lobular features: a comparison study to invasive ductal and invasive lobular carcinomas of the breast: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC39066...

Gully · February 2017

Hello Mellee,

My report also describes my IDC as containing lobular features. As you can see I had IDC in both breasts. One a surprise after surgery. Also I was ER/PR positive and Her2 neg. Negative nodes at least on the left. The right side was never tested. I did not have rads a recommendation from the docs of the tumor board. I did not ask specific reasons for their decision...just ran with it I did have chemo... dx at 45, SBBC, and oncotypes of 5 on right and 19 on left and LVI...gray iffy area. I also had a low proliferation index. Thanks for the article..this information is new for me.

Gully

gardengypsy · February 2017

Yes, I had this pathology. My surgeon called it "tricky lobular."

I don't remember if that had an effect on whether or not I had radiation. My tumor was already large and aggressive at Dx.

EastcoastTS · February 2017

I have IDC (originally diagnosed as ILC) with LCIS. I wonder if I would fall into this camp. Fully expecting a change possibly on final path after surgery 2/27. <?>

kal52 · March 2017

The two papers you posted are very interesting Mellee. I don't know if the knowledge would have changed my treatment but I obviously fit the profile. Have you decided to have the radiation?

Kathy

pupmom · March 2017

Yes, that was also in my pathology report. My biopsy actually stated I was ILC, no mention of IDC. But the tumor was IDC with Lobular features. I had radiation, but no chemo, due to low Oncotype score. Thanks for the articles. They are very informative.

mellee · March 2017

I've decided against radiation. One big factor was that I'm still having wound-healing complications with one of my surgical incisions. So I'm already at 4 months out from surgery -- which is past the most effective window for radiation anyways. And I can't start radiation until I'm fully healed anyways, which could be another month or more.

Meow13 · March 2017

I had one ILC tumor and one IDC. I believe the IDC had lobular features.

Tpralph · March 2017

This is what my initial pathology says as well. I am still in the very early stages of dx and treatment. Seeing my surgical oncologist in two days for initial. Pretty stressed like everyone else! Sleeping pills help lol. thanks for the read, I will look at it.

cling · May 2017

Hi, Just found this thread. Mellee thanks for posting the IDC-L links. My path report 6 years ago was "IDC with lobular features". At that time, I could not find any proper articles, so I just believe that my cancer is IDC. For 6 1/2 years, my CT scan from the very first one in 9/2010 indicated there are possible mets to bones, but all these years my bone scans have always been normal. Even after MD Anderson retested my two bone biopsies and confirmed I did have mets to bone marrow, the bone scans still showed normal. Until a recent CT showed some shadow in my renal fascia and biopsy confirmed the progression. This time the path report said it is a "typical ILC spread" because there is no solid tumor.

I did not believe that IDC will turn into ILC, until someone pointed out that I must misread the original report, then I remember that "with lobular features" term. So IDC-L does have the tendency and possibility to develop into ILC.

lrwells50 · May 2017

My radiologist, a friend, said he's seen a lot of path reports that are IDC with lobular features, but mine is the first ILC with ductalfeatures

Lily55 · May 2017

I had 3 kinds of cáncer - and the Oncologist told me they always take the one that is the largest as the guide for treatment, I had ILC predominantly, some IDC and some LCIS.......I wish I had not accepted radiation as its has left me with ongoing problems

Ashweb901 · September 2018

me too me too me too! I think our hybrid is pretty unique. I have my appt with MO on the 19th, so I’ll know more then, I hope. She is a lobular expert, and I’m hoping she’s up to speed on this little sub-set.

Does anyone know if there are images of our slides stored anywhere? I want to know *which* features of lobular. There’s no standard for path reports to include the detail

mellee · September 2018

I'd be very interested to hear what your MO has to say. Good luck with your appointment!

ctmbsikia · September 2018

I was told I am a mixed type, which by reading this is not the same as IDC-L. Not much activity in the mixed type forum.

My path says invasive mammary carcinoma with ductal and lobular features. However, looking at that tumor on the ultra sound and in the surgeons office it looked to be in the duct. Which is why I just put IDC on my signature. Good info, they study everything. Thanks for posting that study.

Ashweb901 · September 2018

melee, Meow, Lily, Cling: have you all got updates on how your IDC-L is doing and responding/not recurring?

I’ve been studying lobular to see what I can glean before my appointment bc i want my treatment not to be just lumped in to IDC protocols but take into account this oddness - and in my case multifocal x7.

Tamoxifen allegedly does not work for lobular, so that is a major topic I want to discuss. The aromatase inhibitors are better for lobular.

And my surveillance needs to include the other areas where lobular goes - the “wrapping” of the peritoneum, meninges, ureter, etc. it also goes to bones, but i want surveillance on the other stuff too.

I will report back on Wednesday. Please let me know how you are and what you have learned, if anything

Meow13 · September 2018

Ashweb, my cancer has been gone for 7 years. It was removed during mx in Nov 2011 and hasn't been seen since. I did 4 years total AI anastrozole and exemestane. My tumors were 2 masses each 1cm in size.

AI drugs also more effective for er+pr- cancers which mine were.

letsgogolf · September 2018

I think they also refer to IDC/L as mixed type. My reports state it both ways.

cling · September 2018

Ashweb, how did your expert lobular doctor say? I am interested to know more about Tamoxifen is ineffective to ILC. After last year CT finding that cancer is wrapping around me peritoneum, I have gone thru Halaven, Ibrance/Letrozole, and Adriamycin/Cytoxan. The last CT showed stable, so I requested a chemo vacation. I just went on Tamoxifen. This maybe my last oral med. I certainly hope to stay on it for a while.

mellee · February 2019

Just thought I'd report back on my situation. I found a small nodule in my right breast right under the skin and it turned out to be cancer. It has the same pathology as before: IDC with lobular features. Grade 1. Well-differentiated. Strongly ER/PR positive, Her2-, low Ki67. My surgeon and MO believe it is residual disease that was seeded from my original core biopsy.

On ultrasound, it appeared to be only 5 mm, but when my surgeon operated there were 2 foci: one was 1.7 cm and one was 2 mm.

Ashweb -- what did you find out about tamoxifen for lobular? I'd never heard that it wasn't as useful. But it makes sense because my 100% ER+ cancer grew while on tamoxifen. My MO is considering switching me to ovarian suppression + Aromasin.

I did ask my MO about IDC with lobular features and she said there is no difference in the survival rates vs. garden variety IDC. But I'm getting a 2nd opinion on Friday and will grill the MO about this. It seems clear to me from research that IDC with lobular features behaves differently and so I'd like my doctors to really think about how that might impact treatment.

My cancer has behaved oddly from the start, so my assumption is that this will continue!

Georgia1 · February 2019

Hi Mellee and Ashweb901. I have never heard that Tamoxifen "doesn't work" on lobular breast cancer. That's what I'm on now, because I have osteoporosis. Perhaps Ashweb is talking about research showing that some women are just poor metabolizers of Tamoxifen? I discussed that with my MO and decided to do the genetic test for that. I'd be interested in any studies you can share.

mellee · February 2019

Hi Georgia,

I'm just starting my research, but I have found some information that suggests tamoxifen may not be as effective as AIs for ILC. Here's one excerpt from a 2016 journal article (https://www.oatext.com/A-review-of-invasive-lobula...):

Even though ILC responds poorly to neoadjuvant chemotherapy, it has been shown to respond well to endocrine therapy [47]. However, the magnitude of benefit differs with different endocrine therapy. There is also preclinical data that tamoxifen is not an ideal endocrine therapy in ILC patients, with ILC tumour models showing a paradoxical induction of cellular proliferation in response to the drug, suggesting that the estrogen receptor may have different isoforms [48,49], or drive different signaling pathways in the two histological subtypes [50,51]. Differential ER activity between the IDC and ILC has also been suggested at a gene expression level [26]. Clinically, this has also been observed in several retrospective analyses showing that post-menopausal patients with ILC derive more a greater magnitude of benefit from aromatase inhibitors than do patients with IDC [52,53]. Analysis of patients in the Breast International Group (BIG) 1-98 trial showed that letrozole was associated with a 50 – 66% reduction in DFS event risk in ILC patients compared to a 0 – 35% risk reduction in patients with IDC [52]. This difference may however possibly be ameliorated by a switch from tamoxifen to an aromatase inhibitor [54].

But everyone is different, so this doesn't necessarily mean that tamoxifen is never an option for ILC.

mellee · February 2019

Here's another 2016 study:

Differences between invasive lobular and invasive ductal carcinoma of the breast: results and therapeutic implicationshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC49520...

This article discusses tamoxifen vs. AI for patients with ILC, and points to several studies that indicate letrozole is superior to tamoxifen for ILC. However, they also note that data is limited, and needs to be validated by larger studies.

jessie123 · February 2019

Here is another very interesting article on IDC-L or mixed carcinoma. This one makes me happy!

Oncologist. 2018 Dec 5. pii: theoncologist.2018-0363. doi: 10.1634/theoncologist.2018-0363. [Epub ahead of print]

Mixed Invasive Ductal and Lobular Carcinoma of the Breast: Prognosis and the Importance of Histologic Grade.

Metzger-Filho O1, Ferreira AR2,3, Jeselsohn R2, Barry WT2, Dillon DA2, Brock JE2, Vaz-Luis I2, Hughes ME2, Winer EP2, Lin NU2.

Author information Abstract BACKGROUND:

The diagnosis of mixed invasive ductal and lobular carcinoma (IDC-L) in clinical practice is often associated with uncertainty related to its prognosis and response to systemic therapies. With the increasing recognition of invasive lobular carcinoma (ILC) as a distinct disease subtype, questions surrounding IDC-L become even more relevant. In this study, we took advantage of a detailed clinical database to compare IDC-L and ILC regarding clinicopathologic and treatment characteristics, prognostic power of histologic grade, and survival outcomes.

MATERIALS AND METHODS:

In this retrospective cohort study, we identified 811 patients diagnosed with early-stage breast cancer with IDC-L or ILC. Descriptive statistics were performed to compare baseline clinicopathologic characteristics and treatments. Survival rates were subsequently analyzed using the Kaplan-Meier method and compared using the Cox proportional hazards model.

RESULTS:

Patients with ILC had more commonly multifocal disease, low to intermediate histologic grade, and HER2-negative disease. Histologic grade was prognostic for patients with IDC-L but had no significant discriminatory power in patients with ILC. Among postmenopausal women, those with IDC-L had significantly better outcomes when compared with those with ILC: disease-free survival (DFS) and overall survival (OS; adjusted hazard ratio [HR], 0.54; 95% confidence interval [CI] 0.31-0.95). Finally, postmenopausal women treated with an aromatase inhibitor had more favorable DFS and OS than those treated with tamoxifen only (OS adjusted HR, 0.50; 95% CI, 0.29-0.87), which was similar for both histologic types (p = .212).

CONCLUSION:

IDC-L tumors have a better prognosis than ILC tumors, particularly among postmenopausal women. Histologic grade is an important prognostic factor in IDC-L but not in ILC.

IMPLICATIONS FOR PRACTICE:

This study compared mixed invasive ductal and lobular carcinoma (IDC-L) with invasive lobular carcinomas (ILCs) to assess the overall prognosis, the prognostic role of histologic grade, and response to systemic therapy. It was found that patients with IDC-L tumors have a better prognosis than ILC, particularly among postmenopausal women, which may impact follow-up strategies. Moreover, although histologic grade failed to stratify the risk of ILC, it showed an important prognostic power in IDC-L, thus highlighting its clinical utility to guide treatment decisions of IDC-L. Finally, the disease-free survival advantage of adjuvant aromatase inhibitors over tamoxifen in ILC was consistent in IDC-L.

mellee · February 2019

I just saw that study. Very encouraging!

Georgia1 · February 2019

Thank you Mellee and Jessie.

IDC with lobular features - anyone get this DX?

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