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Pathology Report Help

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BlueGreenBaby
BlueGreenBaby Member Posts: 23

Is there anybody who can help me decipher my pathology report? I had a lumpectomy on 12/7, but I don't have an appointment until next week to discuss the results and possible treatments. Does it look bad?

Breast - RIGHT BREAST MASS (OUT OF BODY AT 1111) FINAL DIAGNOSIS

Right breast mass, lumpectomy: -MULTIPLE SMALL FOCI OF INVASIVE DUCTAL CARCINOMA ARISING IN A BACKGROUND OF EXTENSIVE HIGH-GRADE DUCTAL CARCINOMA IN-SITU, DCIS.

-Focally very close (< 1 mm) medial/posterior margins for invasive and in-situ carcinoma.

SYNOPTIC REPORT FOR BREAST CARCINOMA: Procedure: Lumpectomy Laterality: Right Tumor site: Upper inner quadrant as per original biopsy (S21-5113), surgical correlation is suggested. Intact specimen: Yes

Clinical history: Microcalcifications on mammogram Skin/Nipple involvement: Not applicable Skeletal muscle involvement: Not applicable

INVASIVE COMPONENT: Tumor size: Multiple foci ranging from <1mm to 2mm in greatest dimension (largest is block 16)

Histologic Type: Invasive ductal Overall tumor Grade: Poorly differentiated, grade 3 of 3, see note.

Note: Due to the small size of the tumor, precise grading is challenging but overall consistent with poorly differentiated tumor

(tubule formation 3/3, nuclear pleomorphic 2-3/3 and several atypical mitotic figures consistent with 3/3).

Tumor focality: Multifocal DUCTAL CARCINOMA IN SITU, (DCIS): Size (extent) of DCIS: 2.5cm Number of blocks with DCIS: 14 Number of blocks examined: 25

Extensive intraductal component: PRESENT Architectural pattern: Solid and cribriform Nuclear Grade: 3 out of 3 Necrosis: Present

MARGINS: Negative but extremely close * Invasive carcinoma & DCIS both < 1 mm medial/inferior (block 16)

LYMPH NODES: Not submitted Microcalcifications: Not identified
Lymphatic/vascular invasion: Focally suspicious (prominent background artifact)
Treatment Effect: No known prior treatment
Additional findings: Intraductal papilloma/papillomatosis and proliferative fibrocystic changes, biopsy cavity changes.
AJCC TNM STAGING (8th edition): pT1a (m) RECEPTOR STUDIES: In progress (block 16) and will be reported in an addendum.
Ancillary studies. Not performed at this time. If requested, block 16 can be tested.


Comments

  • mfk
    mfk Member Posts: 35
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    I found the booklet referenced here helpful. You can download the pdf. My surgeon hands it out and uses it as a reference to explain the details. Crosses off the parts that aren't relevant, highlights the ones that are, etc. Might help you frame your questions.

    https://www.breastcancer.org/symptoms/diagnosis/ge...


  • mswife
    mswife Member Posts: 67
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    you appear to have a very small grade 3 tumor (invasive ductal carcinoma) with a very small margin on the one side (they may want to go back and take a bit more tissue).

    No lymph nodes submitted (often the case with a lumpectomy).

    Receptor testing is pending (estrogen, progesterone, HER2).

    Hope that helps

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Thank you! I was wondering about the HER2. How long for results? It's been 2 weeks. I am so anxious to see what my treatment plan will be. Once I know all the answers and treatment plan I think I will feel better. Right now it is fear of the unknown.

  • mswife
    mswife Member Posts: 67
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    1-4 weeks for receptors is typical - it depends on where you are located and how busy the pathology lab is

  • beesie.is.out-of-office
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    It looks like you had a lumpectomy after a biopsy diagnosis of DCIS. Based on that, it appears that the surgeon did not perform a sentinel node biopsy (SNB), to check the lymph nodes. This is the appropriate surgical approach with DCIS. However, the final surgical pathology has found several small <1mm to 2mm foci of invasive cancer, and because invasive cancer has been found, your nodes will now need to be checked. Additionally, as MSWife mentioned, you have one very close surgical margin. The margin will need to be increased. Therefore your surgeon will likely recommend a re-excision surgery, taking a bit more tissue where the margin is close, and doing a SNB.

    As for the pathology itself, the presence of invasive cancer does change your diagnosis from Stage 0 DCIS to Stage I IDC. But the invasive cancer foci are extremely tiny, just microinvasions or slightly larger. This is as small as an invasive cancer can get. So to your question, "does it look bad?", the answer is "no, it doesn't look bad". Crappy that it's an invasive cancer rather than pure DCIS (that happened to me too) but still a very small very early stage cancer.

    What's not included in the report is the ER, PR and HER2. Strange that ER and PR aren't noted but HER2 often takes longer. How long depends on whether the result is definitive from the initial IHC testing, or whether a FISH test is necessary, as happens quite often - the IHC test has a large "equivocal" range and anything that falls in that range must be sent for the FISH test. That can take add quite a bit of extra time.

    Did you get ER and PR information from the biopsy? Usually when IDC and DCIS are found together, the ER and PR will be the same; neverthess, the IDC should be checked separately to confirm.



  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Wow thank you that information is very helpful! I didn't get ER or PR information from my biopsy. It just said atypical ductal hyperplasia with highly atypical cells extending into lobules suggestive of DCIS.

  • beesie.is.out-of-office
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    Ah, so until the surgery you only knew for sure that you had ADH. Now everything makes more sense. That explains why you didn't get an ER or PR info from the original biopsy - that's not done for ADH. And that certainly explains why an SNB wasn't done when you had surgery. While the surgical procedure is the same, your lumpectomy technically was an excisional (also called surgical) biopsy; a biopsy is done to determine if any cancer is present whereas a lumpectomy more often is done to remove a known cancer. Some doctors and hospitals do use the term 'lumpectomy' rather than 'excisional biopsy' but it can be confusing.

    Your situation is quite similar to what happened to me. I had a needle biopsy finding of ADH and then had an excisional biopsy that found a whole lot of grade 3 DCIS and a small 1mm microinvasion of IDC. In my case, none of the surgical margins were clear so it was evident that there was a lot of DCIS left in there; as a result my second surgery had to be a mastectomy, along with the SNB. I ended up with over 7cm of DCIS - spread over two different locations in a small breast. In your case, it's likely that a re-excision lumpectomy will be just fine to get the wider margins.

    Let us know how it goes at your appointment next week.

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Thank you Beesie! You have been very helpful! Do you think this means I might need to do chemo or we won't really know what type of treatment I might need to do until I get the HER results? UGH I hate waiting!! I am so anxious over this. Also, since it's invasive, is it spreading while I'm waiting?! This is scary.

  • beesie.is.out-of-office
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    With invasive tumors that are at most 2mm in size, normally chemo would not be considered.

    That said, patients who have small tumors (larger than 2mm though) that are either triple negative (ER-/PR-/HER2-) or HER2+ sometimes do receive chemo. The confusing factor in your case is that you have multiple small tumors. Tumor size is not added together; staging is based on the largest of the invasive tumors, which in your case is 2mm. Normally treatment plans are developed the same way, which means that your invasive cancer would be assessed to be no more than 2mm in size and therefore chemo would not be on the table. But if you are triple negative or HER2+, it's possible that some oncologists might consider the fact that you have multiple tiny tumors, assess it differently and feel that chemo is indicated.

    If you end up being ER+ and HER2+, which is most common, then chemo would not be considered.

    As for waiting, don't worry about that. First off, you've had your surgery and most if not all of the invasive cancer in your breast has been removed - the only question is if there is anything beyond the close margin, and there might not be. The other thing to understand is that most breast cancers are slow growing; by the time a cancer becomes large enough to be detectable, it's already been in the breast for quite a few years. So in the scheme of things, another few weeks is nothing. It's pretty normal to wait 6-8 weeks for surgery.

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Okay that makes me feel slightly better about not needing chemo. I can deal with radiation, but chemo scares the sh*t out of me. Of course I will wait to see what the doctor says.

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Beesie you were spot on! I had my follow up with the surgeon yesterday. It's invasive cancer. I will have to go in for another surgery and he will take a little bit more out around the edges of the first excisional biopsy cavity. He will also take some lymph nodes. Hoping the margins on the second one come out clear, otherwise I will have to have a 3rd surgery mastectomy. I will definitely need radiation. Will have to wait for more pathology reports to see if Tamoxifen is needed. He said most likely not chemo, but again, will have to wait for results.

  • parakeetsrule
    parakeetsrule Member Posts: 605
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    Try not to be scared of chemo! There are definitely side effects but they are very manageable for most people and they are not so bad compared to the alternative.

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Chemo is what scares me the most out of all of this.

  • GardenGold
    GardenGold Member Posts: 1
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    PARAKEETS RULE, I'm a newbie to all of this.

    If I may ask a question ...

    Why did they do chemo first, before your mastectomy ?

  • parakeetsrule
    parakeetsrule Member Posts: 605
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    They wanted to shrink it as much as possible before surgery.

  • beesie.is.out-of-office
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    BlueGreenBaby, glad your appointment went well.

    When I had the excisional biopsy with no clear margins, before my next surgery my surgeon sent me for an MRI. The purpose was to see how much more DCIS appeared to be in my breast, and whether a lumpectomy (which I would have preferred) might be feasible rather than a MX. Turns out that the MRI showed my breast to be full of "stuff" - my surgeon called it "stuff" because we couldn't know if it was benign fibrocystic breast tissue or DCIS. But because I'd had two areas removed during my excisional biopsy, and both turned out to be full of DCIS and there were no clear margins anywhere around either of those two areas, the best guess after seeing the MRI result was that there a lot more DCIS in there, so we went straight to the MX. Turned out that most of the "stuff" was more DCIS. The good news with the MRI is that nothing that showed up had the appearance of invasive cancer. So while it was possible that additional small invasions might be found, at least I knew that was unlikely. In the end, the microinvasion found during my excisional biopsy was the only invasive cancer.

    Your situation is different in that your margins were clear although one or two were very close, which is why the re-excision is necessary. Still, you might want to ask if an MRI prior to surgery could help ensure that clear margins are achieved with the re-excision. There are no guarantees - no imaging is perfect and will be certain to show everything, and some of what an MRI shows could be harmless fibrocystic breast tissue - but doing an MRI prior to a re-excision is not unusual (although not always done).

    My advice... don't worry about chemo. It's a possibility but unlikely - even if you are HER2+ or TN (triple negative), most MOs would not recommend chemo when the largest invasive tumor is 2mm. The only factor that could lean an MO to chemo is that you have multiple small tumors, but if you put two MOs in a room, they would probably disagree about that.


  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Can you help me with this one? I understand the part where it says no cancer found in lymph nodes (yay!!!), but does it mean that the margins were clear? This was for my second lumpectomy.

     TISSUES A. Lymph node - SENTINEL NODE RIGHT AXILLA B. Breast - RIGHT BREAST MASS FINAL DIAGNOSIS
    A. Sentinel lymph nodes, right axilla, excision:
    * No metastatic carcinoma identified in three lymph nodes (three H&E levels evaluated).
    B. Right breast tissue, re-excision:
    * Minute foci of residual tumor identified; margins appear uninvolved. SEE COMMENT
    * Skin and breast parenchyma with reparative changes consistent with recent surgery.
    Comment: There are several minute foci of residual tumor identified in this specimen
    (blocks B6 and B8). Each of these foci measure less than 1mm in greatest dimension and are
    similar to the tumor seen in the original excision. Immunoperoxidase stains were evaluated
    in efforts to distinguish between invasive and in-situ components, but the foci were not
    well represented in the immunoperoxidase stained slides. Based on the H&E evaluation and
    findings in the original excisional specimen (S21-5804), these foci likely represent an
    admixture of ductal carcinoma in-situ and microinvasive components. The margins appear
    uninvolved, but tumor is seen 1mm from the inferior margin and 2mm from the
    posterior-inferior junctional margin. Based on the findings in Part A, the pathological N
    stage is pN0(sn). Please refer to the initial excisional specimen (S21-5804) for the full
    synoptic report.
    IMMUNOHISTOCHEMISTRY: Block B6 and B8: PanCytokeratin, calponin and p63 stains were evaluated.
    However, the tumor foci seen on the H&E slides are not well represented in these slides and are therefore deemed non-contributory
    (see comment above).
    Blocks B4 and B7: PanCytokeratin stains reveal no diagnostic features of invasive carcinoma.
  • minustwo
    minustwo Member Posts: 13,161
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    Did you have this done on 12/28? I imagine you've seen your doc post-op by now. What did your doctor say?

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Yes the 28th was the surgery. I saw him one week later on Jan 4. All results were not in yet at that time. He only could tell me that there was no cancer in the lymph nodes. I will be calling him on Monday. I just saw this posted to my website today.

  • beesie.is.out-of-office
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    "The margins appear uninvolved, but tumor is seen 1mm from the inferior margin and 2mm from the posterior-inferior junctional margin."

    It sounds as though the margins are clear but there is one 1mm margin and one 2mm margin. 2mm is considered to be an acceptable margin. With 1mm, there is debate - with invasive cancer this is considered sufficient but with DCIS, some prefer 2mm.

    "Consensus guidelines support a negative margin defined as "no ink on tumor" for invasive carcinoma treated with breast-conserving therapy. Given differences in the growth pattern and utilization of systemic therapy, a margin of 2mm has been found to minimize the local recurrence risk for women with DCIS undergoing lumpectomy and radiation therapy. Wider negative margins do not improve local control for DCIS or invasive carcinoma when treated with lumpectomy and radiation therapy. Re-excision for negative margins should be individualized, and the routine practice of performing additional surgery to obtain a wider negative margin is not supported by the literature." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5894883/


  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Okay so it looks good, chances are I won't need another surgery. No node involvement so no chemo likely. Though I still do not have my onco score so that's still up in the air.

  • beesie.is.out-of-office
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    Have you been told that you will be getting an Oncotype score? To my understanding, the size of your invasive tumors, with each being 2mm or smaller, are too small to be tested.

    The other issue is that even if a large enough sample could be sent to Genomic Health (the Oncotype company), the Oncotype results are based on a study which didn't include any patients with an invasive tumor as small as your tumors. So that puts into question the validity of Oncotype results for your diagnosis.

    For both of these reasons, an Oncotype score is generally not recommended for those with invasive tumors that are 5mm or smaller. Here are the current NCCN Treatment Guidelines:

    image

    Question: Is your diagnosis line correct? It mentions 2cm of IDC, but the reports you've mentioned indicate that the largest tumor is 2mm.

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Oh I didn't know that. I did ask the surgeon about an oncotype score he said he didn't see one yet. I'm going to ask him when I call on Monday. So with no oncotype score they can still make an educated decision about my treatment? I haven't met with an oncologist yet. Probably next week since he's on vacation this week.

    Maybe I have to change the diagnosis line I got cm and mm mixed up.

  • smoothoperator78
    smoothoperator78 Member Posts: 72
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    I’m so thankful yours was caught so early.

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Yes thank you! Me too!

  • beesie.is.out-of-office
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    "So with no oncotype score they can still make an educated decision about my treatment?"

    That's the Medical Oncologist's job. When I was diagnosed the first time 16 years ago, the Oncotype test was brand new and not very much in use so every decision was made without it. Personally I think that these days too many MOs make a decision by rote based on an Oncotype score, without considering other relevant factors such as the pathology, the patient's age, comorbidities, etc.. It has never made sense to me that someone with an Oncotype score of 28 who is 73 years old and has a 7mm grade 2 tumor will have the exact same metastatic risk as someone with an Oncotype score of 28 who is 51 years old and has a 3.2cm grade 3 tumor. Yet because their Oncotype scores are the same, these two patients will be given the same risk figure and the same treatment will be recommended, if their MOs use only the Oncotype score to drive the treatment decisions. But a good MO will use the Oncotype score as one factor in the treatment decision but not the only factor. In fact even Genomic Health know this, because they have created the RSClin computer model, which they make available to MOs. This model takes the patient's Oncotype score and recalculates recurrence risk by adjusting for patient age, tumor size and tumor grade. Unfortunately very few MOs use this model.

    In my case, with my second diagnosis, my MO didn't run an Oncotype test because he knew that my pathology was barely represented in the studies that are behind the Oncotype scores and recurrence risks - so that put into question whether the results would be accurate for my diagnosis - and because there were factors within the pathology of my cancer that made him certain that regardless of the Oncotype score, he would not recommend chemo for me. I was skeptical but he ran the RSClin model (actually the earlier version, called Oncotype RSPC) and proved to me that even if I'd had a very high Oncotype score, when my age, tumor size and tumor grade were factored in, my risk was low enough that chemo would not be warranted.

    All that to say that while the Oncotype score is a very valuable tool to help with treatment decisions, it is not valid or necessary in all cases and a good MO should know how & when it is appropriate to use, when it is not, and when other patient factors need to be weighed in, possibly changing the treatment recommendation from what it would have been based only on the Oncotype score.

  • BlueGreenBaby
    BlueGreenBaby Member Posts: 23
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    Wow thank you for that! You are very informative! I guess we'll see what my oncologist says about it all.