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Topic: Trying to make sense of surgical pathology changes

Forum: Surgery - Before, During, and After — Surgical options and helpful tips for recovery and side effects.

Posted on: Jan 14, 2022 02:40PM

emstein wrote:

Hi, I'm hoping the wise folks on this site can help me with some questions. I had a lumpectomy on 1/4 and just got my pathology report back yesterday. The good news is that the one sentinel node they found and took out was negative. Also margins were clear (but she did have to take a lot more out than she thought, had a hunch during surgery.)

Here's where things get a bit confusing. Originally, after mammogram, biopsy, and breast MRI, I was er and pr+, her2-, grade 2, 1.5cm, no DCIS detected, no lymphovascular invasion.

The surgical pathology says now I'm grade 3, dcis was present around the tumor, and now it's showing lymphovascualr invasion. And they retested me for Her2 because of the grade change but it still came back negative.

I know things can change after surgery but this seems like a lot. Since the margins and lymph node were clear I'm still considered stage 1a. but I'm trying to wrap my head around what's to come with this new information.

Does grade 3 automatically mean chemo will be recommended? Does grade 3 typically effect oncotype scores? Since I'm er pr+ her2-, does that mean I'm luminal type a? How did you find out your Ki-67? I don't see it on either the biopsy pathology report or the surgical pathology report. Only one lymph node was taken...should they have taken more with the grade 3 change and lymphovascular invasion?

Any insight is most welcome. I'm not panicking. I'm not afraid of chemo and if I need it I need it. I just have so many new questions....


Dx 12/8/2021, IDC, Right, 1cm, Grade 2, ER+/PR+, HER2- (IHC)
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Jan 14, 2022 03:42PM Beesie wrote:

emstein, sorry you've had surprises from the pathology. That is, unfortunately, pretty common.

First off, don't worry about the DCIS. Most IDC, about 85%, has some associated DCIS. That the DCIS wasn't found in the biopsy and was found in the surgical pathology doesn't matter. DCIS is the less serious condition, so other than removal (which has already happened), it can be ignored. Anything done to treat the IDC will be more than adequate to treat the DCIS.

Now, to your questions:

Does grade 3 automatically mean chemo will be recommended? Absolutely not. With your pathology, I expect that your Oncotype test will be the most important deciding factor. It's impossible to know what your Oncotype score will be, but with an ER+,PR+,HER2- node negative cancer, more often than not chemo is not required.

Does grade 3 typically effect oncotype scores? Not directly. Grade is not a factor in the Oncotype calculation, which includes an assessment of 21 genetic components. But grade might affect some of those other components, so it could indirectly affect the score. ER and PR are big factors as well so being ER+ and PR+ will be helpful.

Since I'm er pr+ her2-, does that mean I'm luminal type a? I believe so.

How did you find out your Ki-67? I don't see it on either the biopsy pathology report or the surgical pathology report. Many facilities don't use/report Ki-67. Mine doesn't. If it's not in your report, it probably means that your facility doesn't use it. On it's own, Ki-67 typically does not factor into treatment decisions, however it is one of the 21 genetic components evaluated by Genomic Health when determining your Oncotype score. So your Ki-67 will indirectly be factored into your treatment decisions, through your Oncotype score.

Only one lymph node was taken...should they have taken more with the grade 3 change and lymphovascular invasion? No. First off, there was no way for the surgeon to know during surgery that your tumor was grade 3 or that there was lymphovascular invasion. But more importantly, the process of a sentinel biopsy is what dictates how many nodes are taken. Isotopes and/or blue dye are injected into the breast. Only those nodes that 'light up' with the isotopes and/or dye are removed - those are the sentinel nodes, the first nodes that anything from the breast flow into. Because of how nodes are grouped together, there is no way for the surgeon to know which nodes are sentinel nodes without benefit of the isotopes/dye. Therefore during an SNB, a surgeon will only remove those nodes that have 'lit up' from the isotopes/dye. For some people, that's just one node. For others, it could be as many as 5 or 6 nodes. In your case, it appears that you have just one sentinel node.


Hope that helps!


Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Jan 14, 2022 04:11PM emstein wrote:

Oh Beesie, thank you so so much for your reply! You can't even imagine how comforting it is to have these questions answered. I really appreciate it.

Dx 12/8/2021, IDC, Right, 1cm, Grade 2, ER+/PR+, HER2- (IHC)

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