How do you know if you had LVI or extracapsular extension?
Not sure if this is the right place to post. But I am wondering how people learned whether they had LVI or extracapsular extension or extra-nodal extension (unless that's the same thing)? I am 100% confused!
Is it from core needle biopsies? Sentinel node biopsy? Surgical pathology?
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Hi Sarah, LVI and ECE are noted in the surgical pathology report. LVI can be lymphatic, vascular or both. LVI (lymphatic) was found in my surgical pathology so my surgeon asked the pathologist to check my core needle biopsy slide to see if it was present there. The pathologist's words were “no LVI present in this limited sample," so I guess it could be found in a biopsy. ECE can be found in any lymph node, sentinel or otherwise.
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Surgical pathology of the tumor, and surgical pathology of removed nodes (for extracapsular extension); why are you asking? Have you had your surgery yet?
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Hi Sarah,
My core biopsy showed no LVI but the surgical pathology showed LVI ("present in multiple slides") no other info. I asked both the surgical assistant and my MO about it, and they said it wasn't very important for treatment purposes because I had no positive nodes and lower stage, more like "just a characteristic noted about your tumor". MO said "it could've been the sample getting squished together too much too" when I asked why it wasn't present in the biopsy.
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Thank you for the answers and info! It is interesting that LVI could be seen on surgical pathology but not core biopsy.
laughinggull To answer, I had biopsies (breast tumor and lymph node), then neoadjuvent chemo, then surgery (lumpectomy and SLNB). My surgical pathology report said no invasive cancer (pCR - chemo had killed it all). But it was vague. For example, it didn't mention whether the nodes showed treatment effect (my oncologist had to ask the pathologist to go back and check). It also didn't mention LVI or ECE.
I'm looking at a study about neoadjuvant chemo right now, which DOES take LVI into account. So there must be some way to see it?
It sounds like you had neoadjuvant chemo as well? Do you know if extracapsular extension can be seen on nodes, after neoadjuvant chemo?
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Sarahnh, since the biopsy takes only a small portion of the tumor, it is not a reliable indicator of whether there is LVI present - it could be elsewhere in the tumor.
LVI is sometimes reported on post-NAC surgical pathology as present or absent - I know mine was. My surgeon told me that both DCIS and LVI are more chemo-resistant than breast tumor cells, so that no LVI on a post-NAC pathology report is a very good sign. This study may help explain:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC48760...
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Hi Sarah, LVI is not a good thing but it usually does not affect the treatment plan a great deal. Axillary radiation was added to my whole breast rads because of it, presence of DCIS and micromets in one lymph node. My surgeon told me that if my margins were not clear she would have advised MX but the dangers of an unrecommended second surgery were greater than the possible benefits. My oncotype was 24 and I was HER2- by FISH so I was on the borderline of needing chemo. The statistics, however, didn't recommend it. My oncotype 9 year recurrence is 12% taking AIs and 20% not taking them. I have opted out for many reasons (long story) but this is not relevant to your ER-/PR- tumor biology.
There is another problem with RIPF which has come to light in discussions with my pulmonologist. There are about 300 medications I have to avoid including most treatments for ER+ MBC since they exacerbate PF. Of course, many don't apply to your situation but one of them is Enhertu used for HER2+ mets which would be an option for my HER2-low biology. I'm not planning on recurrence but I know it's a possibility and currently could take only AIs, SERDs and SERMs. There are early stage clinical trials for PDK inhibitors which also inhibit PF progression so I'm hoping these are successful in the event I need them in the future. You might want to check if ILD is listed as a side effect of other treatments for HER2- MBC. Also, ILD increases the risk for lung cancer. I have nodules in my right lung that are being followed for progression. So far they have remained stable and my guess is that they were caused by RIPF inflammation but there are no guarantees.
Sometimes there are no easy answers. Even the experts find that different courses of action are controversial because of contradictory studies or rare situations where no studies have been done.
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Thanks -- this discussion is so helpful!
ratherbesailing - I talked to my surgeon today, and she said neoadjuvant chemo makes it hard to read LVI and ECE. She said ECE is never reported after a pCR, because when the cancer doesn't really leave a cast of itself when it dies. And, tho this part was harder for me to understand, she said LVI would also not be reported after a pCR. I will still follow up and make sure of that!
I think you may have told me but it's hard to remember all the details - was your pathology a pCR in the breast? And do you remember how they worded the LVI findings?
maggie15 - Those are helpful thoughts. I am HR-/HER2+, so the best treatments for a recurrence are Enhertu/Kadcyla/Herceptin/etc. They all carry a risk of pneumonitis/PF. Is that why your pulmonologist said these medications would be excluded? Because the added risk on top of the RIPF is too great?
It is intriguing that you accepted an 8% higher absolute risk of recurrence, to avoid AIs due to other risks.That is the (presumed) upper bound for my own recurrence benefit with PMRT. So it's a very similar situation!
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Hi Sarah, Radiation (and other treatments) can cause slight pulmonary damage that heals itself and which people are unaware of until it shows up on a CT, early stage pneumonitis with ground glass opacities and cough which can be stopped with steroids and leaves minor damage, or very rarely late stage pneumonitis with infiltrates and progressive pulmonary fibrosis which can be fatal. Unfortunately I developed the third version because, in my pulmonologist's opinion, I already had occult ILD caused by gastric acid aspiration evidenced by a former severe upper GI bleed and Barrett's esophagus. High dose steroids and O2 managed to stop the progression before it moved into my left lung but my right lung has pleural thickening, severe fibrosis in the lower lobe, a collapsed middle lobe due to scarring and a mildly damaged upper lobe. I also have to deal with the horrible dry coughing fits that come from the distortion of the lung tissue exposing nerves to air. Any treatment that has pneumonitis/ILD as a possible side effect (including chemo and most MBC drugs) is off the table because it could trigger the fibrotic progression again.
Fortunately as a former competitive swimmer I had excellent lung capacity so my remaining functioning pulmonary tissue keeps me in the satisfactory breathing range. Inhaled corticosteroids have lessened the cough frequency from over 100 a day to about 25. When a coughing fit caused me to pass out during my latest pulmonary function test my pulmonologist added another med which is decreasing the cough even more and improving my SOB on exertion. I am now sleeping for longer intervals at night and can walk 3 miles on level ground. Additionally I need to avoid any respiratory infections (hence my lockdown life) and intubation, but I am very thankful to be here and looking forward to spring when I can do more outside. As far as the AIs go I have several well-controlled medical conditions which could be exacerbated by them so, in my estimation, that risk outweighs the 8% reduction in potential recurrence. If the cancer returns I'll take them since they are one of my few options but they should be effective for a while since the cancer would be AI naive.
Everyone is in a unique situation and you might decide that the 8% risk of skipping radiation is too high for your comfort level. I've had quite the roller coaster ride for the last two years, starting with an oral surgeon telling me I must have cancer since osteomyelitis in my jaw wasn't responding to high dose antibiotics and including so many other complications that my breast surgeon declared I was like a car whose warranty had expired. Other people are way worse off than I am, however, so I will gratefully keep swimming forward and enjoy the waves.
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