get enough treatment without overtreatment

I am 52 years old.

My test results are at the bottom of this. About the lymph node involvement.. the surgeons feel it does not matter. One said it was because I was recently biopsied. I forget what the other one said.

I was given all the options. I did not mention is that if I did a partial mastectomy I would need radiation. Of course they offered the tissue expansion or implant for reconstruction. Also mentioned was that they could do nipple sparing. The 2nd opinion dr did not discuss doing a partial mastectomy.,, felt he would not have enough tissue to close the gap. The DCIS is on the bottom of the breast...so if it is removed then there is nothing to support the top half.

One surgeon said I could have the other breast removed if I wanted to, for cosmetic reasons. It is not a requirement. The other dr was even less interested.. does not agree that you have to remove both. But he wants to do a biopsy of the area.

I have fibromyalgia and have been in 2 car accidents in 3 years. I felt I needed disability before I even had the car accidents or was diagnosed with breast cancer.

Pathology and MRI Report included:

DIAGNOSIS:
A. LEFT BREAST, 3:00 AXIS, STEREOTACTIC CORE BIOPSY:
1. LOBULAR CARCINOMA IN SITU INVOLVING A RADIAL SCLEROSING LESION
AND
WITH ASSOCIATED CALCIFICATIONS.
2. NEGATIVE FOR DUCTAL CARCINOMA IN SITU AND INVASIVE CARCINOMA.

B. RIGHT BREAST, 5:00 TO 7:00 AXIS, STEREOTACTIC CORE BIOPSY:
DUCTAL CARCINOMA IN SITU WITH THE FOLLOWING FEATURES:
1. NUCLEAR GRADE: High grade (grade 3).
2. ARCHITECTURAL PATTERN: Solid.
3. NECROSIS: Focal central necrosis.
4. CALCIFICATIONS: Associated with DCIS.
5. INVASIVE CARCINOMA: Not identified.

Comment: Hormone receptor studies will be performed on part B and
reported in an addendum.

SPECIMEN SOURCE:
A. Left breast SBB, calcific.
B. Right breast SBB, calcific.

CLINICAL INFORMATION:
Fax sheet, report, insurance, film. ICD-10 code is R92.0.

A. Time of removal: 10:11 a.m. Time in formalin: 10:15 a.m.
B. Time of removal: 10:55 a.m. Time in formalin: 11:00 a.m.

Per the accompanying breast imaging report, the patient has a 2 mm
grouping of mildly heterogeneous calcifications in the 3:00 axis of the
left breast. Additionally, a 60 mm span of pleomorphic calcifications
and a linear branching distribution is seen in the 5:00 to 7:00 axis of
the right breast.

MACROSCOPIC DESCRIPTION:
A. SPECIMEN: Received in formalin, labeled with the patient's name,
and "left SBB calcific."
CASSETTE:
NUMBER OF CORES: 7
SIZE:
LENGTH: Ranging from 0.9 cm to 5.2 cm
DIAMETER: 0.3 cm average
FREE-FLOATING CORES: None
INK: Blue
RADIOGRAPH: Present
SUMMARY OF SECTIONS:
A1-A2 Cassette cores, submitted entirely and wrapped

B. SPECIMEN: Received in formalin, labeled with the patient's name,
and "right SBB calcific."
CASSETTE:
NUMBER OF CORES: 6
SIZE:
LENGTH: Ranging from 0.7 cm to 4.5 cm
DIAMETER: 0.4 cm average
FREE-FLOATING CORES: None
INK: Green
RADIOGRAPH: Present
SUMMARY OF SECTIONS:
B1-B2 Cassette cores, submitted entirely and wrapped
NDM/js 10/16/2015

MICROSCOPIC DESCRIPTION:
a-b. Three HE level sections are reviewed for each tissue block. The
accompanying breast imaging report and specimen radiographs for both
parts are also reviewed. The biopsy in part A has a region of sclerosis
and associated sclerosing adenosis that appears to be involved by a
lobular proliferation. Immunohistochemistry for e-cadherin is performed
on block A1 with the appropriate control and is negative within the
lobular proliferation, consistent with involvement by lobular carcinoma
in situ. Additionally, immunohistochemistry for p63 and smooth muscle
myosin heavy chain is performed on both blocks A1 and A2 with the
appropriate controls in order to further evaluate for myoepithelial
cells. Both markers demonstrate an intact myoepithelial cell layer
within this biopsy. There is no evidence of invasive carcinoma in part
A.

This case has undergone prospective intradepartmental quality
improvement review prior to verification.
JBK/or 10/19/2015




Joren B Keylock, MD
Pathologist
Electronically signed 10/20/2015


ADDENDUM:


IMMUNOCYTOCHEMICAL CANCER MARKER STUDIES
MATERIALS
BLOCK: B2
SPECIMEN TYPE: Breast
LOCATION: Right breast, 5:00-7:00 axis
TUMOR TYPE: DCIS
FIXATIVE: Formalin (10% neutral buffered)
DURATION OF FIXATION (>6 AND <72 HOURS)+: Yes
COLD ISCHEMIA TIME (<1 HOUR)+: Yes
ANALYSIS SUMMARY
ESTROGEN RECEPTOR: POSITIVE FOR ER PROTEIN EXPRESSION
Percentage of tumor cells exhibiting nuclear staining++: 98
Staining Intensity: Strong
Internal Controls: Positive
External Controls: Positive
PROGESTERONE RECEPTOR: POSITIVE FOR PR PROTEIN EXPRESSION
Percentage of tumor cells exhibiting nuclear staining++: 55
Staining Intensity: Strong
Internal Controls: Positive
External Controls: Positive
METHODOLOGY
Immunohistochemistry evaluation is performed by manual
quantitative/semiquantitative morphometric analysis.
Immunohistochemical evaluation of estrogen receptor is performed using
Thermo monoclonal rabbit antihuman estrogen receptor alpha clone SP1.
Progesterone receptor evaluation is performed using Thermo monoclonal
rabbit antihuman progesterone receptor clone SP2. Ki-67 evaluation is
performed using DAKO monoclonal mouse antihuman Ki-67 antigen clone
MIB-1. Her-2 neu evaluation is performed using Thermo polyclonal rabbit
antihuman C-erbB-2 clone SP3. Unless otherwise indicated, these studies
are performed using the Thermo automated autostainer, used with paraffin
embedded formalin fixed sections which have undergone heat induced
epitope retrieval in Thermo's Dewax HIER solutiuon. Thermo Ultra Vision
Quanto Detection system HRP DAB is used for visualization.
COMMENTS
+ Per ASCO/CAP guidelines, ideal fixation times for ER/PR and HER2 IHC
evaluation are >6 and <72 hours; cold ischemic time should be <1 hour.
Puget Sound Institute of Pathology HER2 validation and ongoing
monitoring of IHC and FISH assays demonstrate an extremely high
concordance (>95%) that is independent of the reported duration of
fixation. However, if cold ischemic time and fixation time do not meet
published guidelines, repeat analysis on alternative material is
suggested if clinically indicated.
++ If less than 1% of tumor cells are positive for estrogen or
progesterone receptor, the tumor is considered to be negative for the
hormone receptor expression per ASCO-CAP 2010 guidelines.
+++ A false negative result cannot be ruled out in the presence of
inadequate controls.
++++ Negative (0) no staining observed or membrane staining that is
incomplete and is faint and within less than or equal to 10% of the
invasive tumor cells; Negative (1+) incomplete staining that is
faint/barely perceptible and within > 10% of invasive tumor cells;
Equivocal (2+) circumferential membrane staining that is incomplete or
weak/moderate within > 10% of invasive tumor cells; Positive (3+)
circumferential intense complete membrane staining in contiguous
population > 10% invasive tumor cells.
+++++ When discordance exists between cell proliferation as determined
by Ki-67 antigen and histologic mitotic count, the higher of the two
determinations should be used. Ki-67 antigen is sensitive to tissue
fixation and may show a falsely low proliferation index.
NOTE: Some of the immunocytochemistry tests used at Puget Sound
Institute of Pathology have not been cleared or approved by the U.S.
Food and Drug Administration. The FDA has determined that such
clearance or approval is not necessary. These tests were developed and
their performance characteristics determined and verified by Puget Sound
Institute of Pathology. These tests are used for clinical purposes and
should not be regarded as investigational or for research. Additional
information about these tests is available upon request. This
laboratory is regulated under the Clinical Laboratory Improvement
Amendments of 1988 (CLIA) as qualified to perform high complexity
testing.
References: 1. Wolff AC, Hammond ME, Schwartz JN, et al. American
Society of Clinical Oncology/College of American Pathologists guideline
recommendations for human epidermal growth factor receptor 2 testing in
breast cancer. Arch Pathol Lab Med 2007;131:18-43.

JBK/js 10/20/2015



Joren B Keylock, MD
Pathologist
Electronically signed 10/20/2015

----------------------------------------------------------------------------

DATE OF SERVICE: 11-02-15

EXAM: MRI BREAST BILATERAL
ACCESSION: 3236863

HISTORY: Recently diagnosed ductal carcinoma in situ of the right breast.
Lobular carcinoma in situ and radial sclerosing lesion of the left breast.

TECHNIQUE: Breast MRI was performed with an 8 channel coil. Sequences
obtained included axial T2 fat sat, pre-contrast axial T1, post-contrast
T1 every 90 seconds for three sequences and high resolution sagittal
sequences. Subtraction axial images were
generated. Axial 3D SPGR images were also obtained. Sagittal
reconstructions were performed.

9 cc of MultiHance intravenous contrast were injected without incident.

The study was processed using a CADstream system to optimize
interpretation by generating multiplanar and three dimensional
reconstructions, by creating subtraction images from the dynamic pre- and
post-contrast data and by providing enhancement kinetic
and analytical information.

COMPARISON STUDIES: None

FINDINGS:
RIGHT BREAST:
I reviewed the patient's mammogram. There are pleomorphic calcifications
within the lower inner aspect that span approximately 6 cm. These
calcifications are associated with ductal carcinoma in situ. On the
patient's MRI the susceptibility artifact
is noted in the lower inner aspect at the site of biopsy. There is
however no specific enhancement on the MRI. There is a large amount of
background enhancement throughout the breast. I do not identify a mass at
the known site of DCIS.

There are 2 prominent intramammary lymph nodes which are suspicious for
nodal metastasis. These are very caudal in location anterior to the right
lobe of liver. No enlarged or abnormal appearing axillary lymph nodes.

LEFT BREAST:
There is mild to moderate parenchymal background enhancement. There is
susceptibility artifact in the inferior aspect of the breast which is the
area of known LCIS. No specific enhancement of the known lobular
carcinoma in situ.

Elsewhere no enhancing mass or areas of worrisome nonmasslike enhancement.
No enlarged or abnormal appearing axillary or internal mammary chain
lymph nodes.

IMPRESSION:
RIGHT BREAST:
1. The biopsy-proven DCIS is essentially occult on MRI. Based on the
mammogram the calcifications which are associated with DCIS span 6 cm in
length.

2. There are 2 abnormal appearing internal mammary chain lymph nodes.

LEFT BREAST:
1. Area of known LCIS is occult on MRI.

ASSESSMENT: ACR BI-RADS Category 6 - Known biopsy proven malignancy.



RECOMMENDATION:
1: Appropriate treatment.


Per National MQSA guidelines, a breast imaging result letter will be
provided to the patient.



Reported: 02 Nov 2015 11:24 ANDREA MANZO
Electronically Signed: 02 Nov 2015 14:17 ANDREA MANZO

Sorry I forgot to mention.. it is Grade 3 Stage 0.

The dr didn't explain it that way to me... that it was at a great risk of becoming invasive cancer. He was just focused on the size.To me bigger size does not automatically mean bigger risk.. it's probably not been tested (how size affects risk). But you guys are saying that other stuff in the report is showing it is at greater risk of becoming cancer than other DCIS lesions might be. No dr discussed that with me... that's pretty bad. He did say it could already be invasive but we won't know it until it is removed.

My Mom had a lump years ago, When it was biopsied no cancer was found. Her surgeon said he wanted to remove it anyway. Cancer was found. She had to have radiation. She said the radiation did not bother her. She is cancer free now.

I just sent an email to Dr Esserman.

More responses from her...

"You can send an oncotype DCIS and if low or intermediate risk, you can think about hormonal therapy first to see how it goes"

Also mentioned an aromatase inhibitor but said it might not be appropriate for me.

I don't think she read the report I posted above because she seems to not know info that is in the report

I am wondering does it even matter if you guys have the definitions of the terms correctly identified. They are saying it is grade 3, a large area etc... whether or not that it really will become invasive in the future cant be predicted yet until more studies are completed. Also since I have two different things in each breast the dr says it shows my breasts are "good at making stuff".

Does anyone know if these things that Dr Esserman brought up are done before surgery or after? (She has not seen me in person so her comments are affected by that...)

endocrine risk reduction

oncotype DCIS

aromatase inhibitor

It is perfectly ok with me if you guys want to discuss the nuts and bolts of everything.. I am interested in it too. I am just in the mode of having to decide what my next actions need. I was clarifying it for myself.

I was called back.. the nurse who called didn't know what endocrine risk reduction was.. Said the other stuff would be after my pathology on the removed tissue. The oncologist would decide.

I set my surgery date.. Feb 24 I am supposed to have dye put in the sentinel node (or whatever the right terms are). Then the next day have a wire placed and surgery the same day.

It was very hard for me to decide what to do because anything had tremendous drawbacks attached to it. Obviously I would want to keep my breast if I could. But with it being such a big area, and studies not completed on who can go without mastectomy it is better to err on the side of caution. (Also I have a strong family history of cancer.) I was not sure if I should do the reconstruction or not. Yes you can do it at a later time but then you won't be able to have nipple sparing. I was afraid of the problems reconstruction might bring. would it make me less functional because the muscle could be damaged or the tissue might not get enough blood supply etc. If I did implants they have been known to leak, cause cancer, etc. Newer ones are out there but too new to know the dangers. Also the breast surgeon (not the plastic surgeon) said that implants would not be good for me because of the shape of my breasts. (Thanks a lot, plastic surgeons for not telling me that.)

Thank you everyone for your help! Continue to discuss whatever you want it is ok with me

I believe I am going through menopause but have not had it confirmed by a test or anything.

Yes thanks for spelling it out in detail BarredOwl. I will check out that forum. One question is why do they need to use a wire when they already have the clip put in from the first biopsy? I thought that was the point of the clips.. so someone in the future could see where the biopsy was removed from

BlueHeron yes it is confusing... I am assuming not a lot of people have both breasts with something needing to be done to each one at the same time.

Dr Esserman responded back. She said the things she listed should be done before the surgery.