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Topic: Desperate for information/help

Forum: Just Diagnosed — Discuss next steps, options, and resources.

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Posted on: Jul 20, 2007 10:31 AM

K9Mom wrote:

My beloved mother-in-law was just dx'ed with breast cancer on Wednesday. We met with the surgeon today and received the path report. He says it's DCIS. Surgeon is telling us that the choice is hers to make, but is recommending a lumpectomy with 5 weeks of radiation, 1 day per week.

I work for an internal medicine doctor and my gut is telling me that she should do a mastectomy, not a lumpectomy...but I've never dealt with breast cancer before other than seeing our patients who have dealt with it. Surgeon says DCIS but path report uses the terminology "infiltrating" and that scares me...as well as being grade 2.

This is what the path report says, and I would like any and all comments on it and help understanding it please.

PATH REPORT
Estrogen receptor positive with strong 3+ nuclear staining intensity in 95% of invasive tumor cells.
Progesterone receptor positive with weak nuclear staining intensity in 30% of invasive tumor cells.
HER2 oncoprotein positive 2+. Uniformity of staining is present with 40% of invasive tumor cells exhibiting intermediate or positive membrane staining. Homogenous, dark circumferential membrance patern is present. Internal and high protein, low protein, and negative protein controls are satisfactory.

All HER2 equivocal (2+) cases reflexed for HER2 FISH analysis per ASCO/CAP HER2 testing guidelines. Log in to post a reply

Posts 1 - 12 (12 total)

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Jul 20, 2007 10:46 AM nash wrote:

The survival rates of lump/rads vs. mast. are the same. The issue would be if the surgeon can get clean margins with the lumpectomy or not. That will depend on the size of the tumor and its location.

I don't understand why the path report says invasive and the surgeon says DCIS. Is there any other info on the path report that explicitly states DCIS?

Grade 2 is a middle grade, meaning the cells are moderately differentiated. Grade 3, poorly differentiated, is more aggressive.

Your MIL is ER+/PR+. which is good, b/c she can get hormonal treatment, such as tamoxifen. She is also HER2+, which is bad and good at the same time. It's bad in that it means the cancer is more aggressive than one that is HER2-, but it is good because she can receive Herceptin, which is of tremendous help to many HER2+ women.

In addition to the HER2 section of these discussion boards, there is an outstanding HER2 support site you may want to check out: www.her2support.org.

Sorry your MIL had to join the bc club. I've been on both sides of this--my mom is Stage IV IDC, and I just had surgery (yesterday!) for ILC, possible Stage IIIB, at age 39. My father, grandfather and father-in-law all have died of cancer. It bites to be the patient, and it's awful for the family members.

You're doing the right thing by getting as much info as you can to help your MIL. Good luck to both of you!
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Jul 20, 2007 10:51 AM LisaSDCA wrote:

First thing I would do is ask him for the REST of the pathology report. There is nothing here that says DCIS or Grade 2. What you have included is simply the receptor status. It is strongly estrogen positive, mildly progesterone positive, and apparently Her2 positive, but will be confirmed with FISH analysis.
I agree with you that there does seem to be an invasive component. Perhaps your mother-in-law could have a consultation with an oncologist before making any surgical decision.
Good luck! These early days are the toughest ones.

Lisa
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Jul 20, 2007 11:04 AM K9Mom wrote:

Thank you both. I just realized that I cut off the final diagnosis portion by trying to make it a colored font....sorry. Her tumor is only 1cm in size.

FINAL DIAGNOSIS:
Left breast mass (needle core biopsy)
- Intraductal and infiltrating ductal mammary carcinoma (Grade 2)
- Extensive areas of microcalcifications are present in this region of infiltrating mammary carcinoma.
- Tumor occupies 60% of the submitted tissue.
- Areas of ductal carcinoma in situ show a solid and cribriform pattern.
- Tumor shows intermediate nuclear grade.
- No vascular or lymphatic invasion by tumor is identified.
- Estrogen, progesterone and HER/2 neu studies are performed and a report will be issued in a supplemental report.
- Areas of florid ductal hyperplasia of the usual type, apocrine metaplastic change and occasional areas of sclerosing adenosis are identified.
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Jul 20, 2007 11:40 AM Hope_M wrote:

I do not believe that this is limited to DCIS--that is only in the ductwork. If she has a tumor, she has invasive cancer already. If the scans also show microcalcifications in a broader area, I agree that the proper course is a mastectomy.

She may want to request a breast MRI, if she is hesitant about the mastectomy.

The scans and needle biopsies are not definitive for what is really going on in there, as you probably already know. The reality may be that the cancer is in more places, or is larger than the scans indicate.

Best of luck!

Hope M.
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Jul 20, 2007 11:42 AM Hope_M wrote:

Just re-read the top post on this. I've never heard of rads being given one day per week. Usually it is 5 days per week. Is this a new protocol?

Also, the lymphatic and/or vascular invasion cannot be determined from the biopsy cores. This report is not saying that that level of invasion has not occurred; it is saying that the cores do not reveal it.

Hope M.
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Jul 20, 2007 11:56 AM K9Mom wrote:

THANK YOU so much for your insight!!
What, if any, other diagnostic tests should we ask for? Would an MRI be helpful? We see another surgeon on Thursday for a second opinion.
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Jul 20, 2007 12:05 PM Coltsneck wrote:

Don't be too frightened by the words "infiltrating" or "invasive" as they do not mean that the cancer has spread to other parts of the body. It is possible to have both DCIS and IDC (Invasive Ductal Carcinoma) in different parts of the breast. If there are multiple tumors, the surgeon may recommend a mastectomy even if the cancer is in early stage. You need a bit more info and advice from another physician - perhaps the oncologist as Lisa has recommended. I never heard of radiation one day a week - it is usually 5 days a week following lumpectomy. Most times radiation is not needed following a mastectomy.

The important thing is not to let the fear grip you - stay calm (I know, easy for me to say), gather as much information as you can without being overloaded with data, write down all your questions, and always have two people in the room with the doctor. It's amazing what you info you can miss or confuse (e.g., your doctor may have said rads 5 days a week for 5 weeks).

Good luck - we're all rooting for you and your MIL.
Maureen
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Jul 20, 2007 12:13 PM dawnjs5k wrote:

According to all of the info that I have received, a HER 2 done by staining, a 1 - 2+ is not considered positive. It is good that they are going to do the FISH for the results. That gives a number. The other is a grading system. Mine was considered a 2+ and the oncologist said that it was not HER2 dependent. Mine was very small, so there was not enough cells after 3 opinions, multiple stains locally, and receptor testing for them to send for FISH. I am very new to all of this, but I would assume that she would need an MRI. This is what the oncologist told me is the new standard of testing for young women with history and for those diagnosed with breast cancer. I am sorry to hear that she is going to have to go through this, but I am glad that you are there to support her.

Dawn
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Jul 20, 2007 12:24 PM Shirlann wrote:

Hi, if it is just DCIS, she is not in any danger for her life, DCIS is not life-threatening. It is "in situ", or, in english, still in place, it has not "broken through" to any other part except the part it started in.

To just do a mast, willy,nilly, is not always the best approach. Dr. Susan Love actually prefers a lumpectomy, if clean margins are possible, because in case of a recurrence, there is tissue to work with, versus working with the chest wall. So a mast is not a cure-all for every situation.

Now, if you are uncertain, or if she is uncertain, go to a breast clinic, take the slides and everything else, and get a second opinion.

This will put everyone's mind at rest. (Do not go to her current doc's friends, they always back each other up)

Gentle hugs, Shirlann
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Jul 20, 2007 03:30 PM K9Mom wrote:

Thank you all for your assistance and information. I can't thank you enough. Yes, I am freaking out because we buried my Mom's best friend due to liver mets on the same day that my mother-in-law was diagnosed. I'm trying to stay calm and I am positive around my MIL but the worry inside of me is overwhelming.
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Jul 21, 2007 05:13 AM Hope_M wrote:

Re: the breast MRI--it is a more sensitive scan and would show any additional areas of concern in the breasts. It might also confirm the size of the tumor.

Let us know how it all goes-

Hope M.
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Jul 21, 2007 06:31 AM Beesie wrote:

Looking at your MIL's pathology, what she has is IDC - "Intraductal and infiltrating ductal mammary carcinoma", not DCIS. There is a component of DCIS in her pathology, but DCIS is Stage 0 breast cancer whereas IDC is Stage 1 (or it could be higher). In diagnosing BC, the more aggressive cancer always trumps anything lower. So someone with DCIS and IDC is considered to be an IDC patient.

Because your MIL has IDC, an important piece of information will be her lymph node status. From her pathology report, it doesn't appear that her lymph nodes have been tested yet, so this will have to take place during her next surgery. Her lymph node status, along with the overall size of her tumor, will determine the stage of her breast cancer. It will also determine what other treatments - chemo, hormone therapy - may be necessary.

All of this doesn't necessarily affect your MIL's surgery decision. Lumpectomy or mastectomy.... always a difficult decision. Sometimes, if the tumor is large or in more than one quadrant of the breast, there is no choice and a mastectomy is the only option. The rest of the time, it's a matter of personal choice based on a number of considerations. As nash mentioned, the survival rate between lumpectomy w/ radiation and mastectomy is the same, however the recurrence rate for lumpectomies is higher. This higher recurrence risk can be reduced by taking hormone therapy drugs such as Tamoxifen.

Some of the considerations in the decision:
- How will your MIL feel about losing her breast? Some women want to avoid this, while other women feel better "just taking the whole thing off".

- How will your MIL deal with recurrence risk? If your MIL's cancer has not moved beyond the breast, a mastectomy would probably reduce her recurrence risk to 1% - 2%. (Note that this wouldn't be the case if it turns out that there is some lymph node invasion). With a lumpectomy w/ radiation, and if she adds hormone therapy, her recurrence risk may be in the range of 5% -10% (my numbers are estimates; her actual risk depends on her final pathology and only her doctor can give her the correct numbers). Would your MIL continually panic if her risk is 10%, or is this something she could easily live with?

- How does your MIL feel about radiation and hormone therapy? With a mastectomy, radiation often can be avoided, although there is no guarantee. If there is lymph node involvement or if the tumor is close to the chest wall or skin, even with a mastectomy, radiation might be required. But often it's not required whereas with a lumpectomy, radiation is pretty much the norm. As for drug therapy, after a mastectomy, if there is no lymph node involvement, hormone therapy is usually considered optional. Since the recurrence risk is so low (unless there is lymph node involvement), the main benefit would be protection of the remaining breast. However after a lumpectomy, because there is a higher recurrence risk, hormone therapy is a more important part of the treatment plan.

Those are just some of the considerations. The important thing to keep in mind is that this is a very personal decision. Having participated on this board for about 1 1/2 years now, I think I can safely say that no one should ever try to convince someone who wants a mastectomy to not have one, and to have a lumpectomy instead. They likely will live in fear of a recurrence, and regret not having had the mastectomy. On the other hand, if a lumpectomy is a viable option based on the size of the tumor, and if this is the surgical choice that the patient is most comfortable with (understanding all the implications with regard to recurrence risk, radiation, hormone therapy), then it is wrong to try to convince the patient to have a mastectomy. A mastectomy can be a relief for someone who wants this surgery; for someone who doesn't want this surgery, a mastectomy can be traumatic and live-changing. It's not something that you want to push someone into if it's not their choice.

Sorry for being so long in my response, but I hope this helps.

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