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Lani · 12-30-2007, 06:43 PM

Some questions:

on your friend's biopsy report:

1)is it the DCIS that is ER+PR+ and her2+ or the area of infiltrating ductal carciinoma or both?

2)Also. did they give a size for the multiple foci? Were they areas of microinvasion or were they macroinvasion.
How large a tumor specimen(s) did they remove? You make it sound like they used "a wire" and removed"an area" The reason I ask is that multicentric breast cancer is described as being treated differently than "a tumor" or DCIS with one or several areas of microinvasion.

3)Did you friend get a Ki67 number? It gives information on how fast the tumor is growing (which implies how aggressive it is)--with the description of well differentiated and stage I, there may not have even been any Ki67 staining to be seen !!! (a great sign)

Some comments/information:

With respect to the MRI--studies show it can change the recommendation of what surgery should be done and /or how the surgery is done in 20-30% of cases or more.You can't know know the implications of what it might find until the MRI is done and the results known.

Pre-operative chemotherapy , called Neoadjuvant chemotherapy, is usually given for Stage T2 and above, as smaller than that makes it hard to determine if the preop therapy worked or not (the advantage with a bigger tumor with neoadjuvant treatment is, if it didn't, they can know that right away and go right ahead and try another)

Yes, PET/CT also can show false positives--but may take a while to schedule as I understand it there usually is quite a wait to get them at most institutions and recently there has been a shortage of the radioactive tracers needed to do them (Canadian nuclear plant that makes them shut down). From my understanding a PET/CT can still be interpreted if done post operatively. I guess the operative question is whether finding positive results before the surgery would change the proposed upcoming surgery--a good question to ask, it seems.

Unfortunately, PET/CT results are not yet accurate enough to allow her surgery to avoid sampling her lymph nodes (something they might not do if she had only low grade (vs the high grade she has) DCIS without the invasion.

You might want to contact Jean on this board.

I wouldn't be surprised if she suggested your friend ask for an OncoDx test. Jean had a very small tumor but her OncoDx test showed high risk of recurrence so she consulted with Dr. Slamon (who"invented" herceptin) and was treated with chemo and herceptin and now antihormonals
for what, at the time she developed it. official "guidelines" would have treated her with chemo and antihormonals (US) or with antihormonals alone (UK). I believe she is now 2 years out. Not all insurances pay for the test I believe, but the number that do is reportedly growing as more and more papers come out about its help in making treatment decisions. See if you can email or PM her--I am sure she would help.

I know Dr. Slamon has said that he thinks the OncoDX doesn't tell you anything that a good ER, PR , FISH for her2 and Ki-67. But your friend's tumor seems unusual in the following way: most her2+ tumors are not well differentiated

The OncoDx test is still in a clinical trial to determine if it should be used to guide treatment and allow some patients with very low likelihood of recurring or metastasizing to avoid chemo. In the EU tumor guidelines were such that small ER+ tumors which were her2- have for many years been treated without chemo(St. Gallen guidelines)

The good news is that they found your friend's tumor early that it sounds like it is tiny (you didn't gave a size or sizes) and sounds as if it is very unagressive ie, well-differentiated and Grade I. If only the DCIS and not the invasive component was her2+, then according to my readings and conferences I have attended, current US guidelines recommend giving chemo to every patient with an ER+ patient with an invasive component, no matter how small. Recent research has tended to shown chemo to be ineffective in these ER+her2- tumors and
I guess the standard of care will change with time. In the meantime, an OncoDx test might make your friend and the doctor more comfortable discussing other options.

So a lot depends on whether only the DCIS was her2+ or if the inflltrating foci were as well. If your friends infiltrating tumor is itself her2+,it would be most unusual, as her2+ tumors are RARELY Grade I. If there is any doubt, there is such a thing as a second pathologic opinion (you just arrange to send the slides).

I am in no way qualified to advise on these matters, but am well-read and post information frequently. Welcome to the board.

You have one lucky friend (to have you on her side)!

12-30-2007, 06:43 PM	#3
Lani Senior Member Join Date: Mar 2006 Posts: 4,778	Lin-- Some questions: on your friend's biopsy report: 1)is it the DCIS that is ER+PR+ and her2+ or the area of infiltrating ductal carciinoma or both? 2)Also. did they give a size for the multiple foci? Were they areas of microinvasion or were they macroinvasion. How large a tumor specimen(s) did they remove? You make it sound like they used "a wire" and removed"an area" The reason I ask is that multicentric breast cancer is described as being treated differently than "a tumor" or DCIS with one or several areas of microinvasion. 3)Did you friend get a Ki67 number? It gives information on how fast the tumor is growing (which implies how aggressive it is)--with the description of well differentiated and stage I, there may not have even been any Ki67 staining to be seen !!! (a great sign) Some comments/information: With respect to the MRI--studies show it can change the recommendation of what surgery should be done and /or how the surgery is done in 20-30% of cases or more.You can't know know the implications of what it might find until the MRI is done and the results known. Pre-operative chemotherapy , called Neoadjuvant chemotherapy, is usually given for Stage T2 and above, as smaller than that makes it hard to determine if the preop therapy worked or not (the advantage with a bigger tumor with neoadjuvant treatment is, if it didn't, they can know that right away and go right ahead and try another) Yes, PET/CT also can show false positives--but may take a while to schedule as I understand it there usually is quite a wait to get them at most institutions and recently there has been a shortage of the radioactive tracers needed to do them (Canadian nuclear plant that makes them shut down). From my understanding a PET/CT can still be interpreted if done post operatively. I guess the operative question is whether finding positive results before the surgery would change the proposed upcoming surgery--a good question to ask, it seems. Unfortunately, PET/CT results are not yet accurate enough to allow her surgery to avoid sampling her lymph nodes (something they might not do if she had only low grade (vs the high grade she has) DCIS without the invasion. You might want to contact Jean on this board. I wouldn't be surprised if she suggested your friend ask for an OncoDx test. Jean had a very small tumor but her OncoDx test showed high risk of recurrence so she consulted with Dr. Slamon (who"invented" herceptin) and was treated with chemo and herceptin and now antihormonals for what, at the time she developed it. official "guidelines" would have treated her with chemo and antihormonals (US) or with antihormonals alone (UK). I believe she is now 2 years out. Not all insurances pay for the test I believe, but the number that do is reportedly growing as more and more papers come out about its help in making treatment decisions. See if you can email or PM her--I am sure she would help. I know Dr. Slamon has said that he thinks the OncoDX doesn't tell you anything that a good ER, PR , FISH for her2 and Ki-67. But your friend's tumor seems unusual in the following way: most her2+ tumors are not well differentiated The OncoDx test is still in a clinical trial to determine if it should be used to guide treatment and allow some patients with very low likelihood of recurring or metastasizing to avoid chemo. In the EU tumor guidelines were such that small ER+ tumors which were her2- have for many years been treated without chemo(St. Gallen guidelines) The good news is that they found your friend's tumor early that it sounds like it is tiny (you didn't gave a size or sizes) and sounds as if it is very unagressive ie, well-differentiated and Grade I. If only the DCIS and not the invasive component was her2+, then according to my readings and conferences I have attended, current US guidelines recommend giving chemo to every patient with an ER+ patient with an invasive component, no matter how small. Recent research has tended to shown chemo to be ineffective in these ER+her2- tumors and I guess the standard of care will change with time. In the meantime, an OncoDx test might make your friend and the doctor more comfortable discussing other options. So a lot depends on whether only the DCIS was her2+ or if the inflltrating foci were as well. If your friends infiltrating tumor is itself her2+,it would be most unusual, as her2+ tumors are RARELY Grade I. If there is any doubt, there is such a thing as a second pathologic opinion (you just arrange to send the slides). I am in no way qualified to advise on these matters, but am well-read and post information frequently. Welcome to the board. You have one lucky friend (to have you on her side)!