Friday, February 10, 2012 Judy asks

Q: DCIS - please help with pathology report

I got the results of my biopsy last night and my pathology report today and was hoping someone could help me to understand my diagnosis and my options. I've done a little research, but am having trouble finding information on some of the items on the pathology report. I'll copy the parts that I think are the most relevant:

Ductal carcinoma in situ, solid type, with apocrine features, intermediate nuclear grade, with necrosis and calcifications. DCIS measures 0.9 centimeter in greatest histological extent and involves five core biopsies with additional fragments of DCIS embedded in blood coagulum.

Estrogen Receptor: positive (1-3+ staining in 90% of DCIS nuclei).

Progesterone Receptor: positive (1-3+ staining in 99% of DCIS nuclei).

I understand the diagnosis of DCIS, the type, and the grade. I believe the necrosis indicates more rapid cell division, so I assume that's a sign that it's somewhat more aggressive than DCIS without necrosis; is that correct? Can someone tell me the significance of apocrine features and fragments embedded in blood coagulum?The positive hormone receptors means that I may be a candidate for certain medications, if I understand correctly.

The pathologist told me I'd probably have a lumpectomy and radiation. I'm not the kind of person that wants to do the most radical thing "just in case." I'm reluctant to even take antibiotics when I'm sick. I prefer the most natural and gentle approach possible. I know that with a diagnosis of cancer, I'll have to be flexible, but I refuse to let them start slicing and irradiating me without at least having examined all my options.

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Answers (2)

PJ Hamel, Health Guide

2/10/12 8:43pm

Hi Judy - Welcome to the club no one wants to join! Thankfully, DCIS is the most treatable form of breast cancer, and one of only two types (LCIS is the other) where your oncologist will actually tell you you're cured; the overall 5-year survival rate for DCIS is about 99%.

Pathology reports can indeed be tough reading; our Guide to Understanding your Pathology Report is very helpful, and check out this explanation of some of the more arcane terms you mention from Johns Hopkins/Avon Foundation.

Necrosis is simply a sign of cancer; of normal cells being killed by cancerous cells. I don't believe it's related to aggressiveness. Nor do I think DCIS in blood coagulum is anything important, since DCIS is by definition not invasive. But you'd best ask your oncologist for clarification when you see him/her.

The treatment they've proposed for you is standard, and has been the treatment of choice for decades. You can, if you choose, not treat this at all. Some researchers now believe that DCIS is a pre-cancer, some cases of which might never develop into anything more serious, even when left untreated. In fact, a recent study estimated that up to 66% of DCIS breast cancers might never progress, even when left alone. Problem is - do you want to leave this untreated, and hope you're in that 66%? Check out our post on this Norwegian DCIS study.

Truthfully, a lumpectomy (breast conservation surgery) and radiation are fairly non-aggressive, as far as cancer treatment goes. The process would take several months, but then you should be right back on the path to good health. That said, if you choose not to treat this; or to treat it only with surgery, don't let anyone bully you into treatment you don't want. It's your body; and your decision. Best of luck to you - PJH

Judy

2/10/12 9:05pm

Thanks for your quick reply. I should have mentioned that I'd read the very helpful Guide to Understanding Your Pathology Report as well as the list of terms on the Johns Hopkins/Avon Foundation site. I didn't see much about apocrine features, but I'm starting to think that's not terribly important.

Your take on the necrosis is comforting and after reading the report about a million times I'd come to the same conclusion on the DCIS in blood coagulum. Since it was mentioned in the same part of the report when he was giving measurements, I'm guessing he was just adding up all the places it was found. I will ask the oncologist though.

I'll probably end up doing what they say, even though it really bothers me. I do have a strong family history of breast cancer (both sides of my family). I just don't want to make an uninformed decision. Some sites that I've read say that it's not really cancer and most of the time doesn't become cancer. Then I'll read another site that says don't mess around, it's cancer and it's serious. The thought of exposing myself to radiation and taking pharmaceutical drugs for five years and having surgery for something that might not even become "real" cancer just rubs me the wrong way. I'm just not a huge fan of western medicine, although I know it can be life-saving. But if my life's not in danger, I'd rather stick to my more natural approach. My GP provides integrated care (western and alternative), but he told me today I need to have surgery.

Thank you again for taking the time to respond and for your support.

PJ Hamel, Health Guide

2/10/12 9:51pm

You're very welcome, Judy. You know what might be helpful? Have your oncologist lay out for you the various risk of recurrence rates: with surgery alone; with surgery + radiation; and with surgery, radiation, + hormone therapy. Get the absolute risks, not relative; e.g., "Your risk of recurrence with surgery alone is 10%; with surgery and radiation, it's 8%" - instead of "with surgery and radiation, it's reduced by 25%." When you see all the numbers in stark black and white, it's sometimes more clear that, for a 2% reduction in risk, radiaiton might not be worth it to you. Or, if the drugs bring your risk down by 5 percentage points, maybe you think they are worth it. It's all a numbers game, and boils down to - how do the possible benefits stack up against the possible side effects; and, how lucky do you feel? It's a roll of the dice; a well-informed roll, but still a game of chance... In the end, you'll do what your heart tells you; and the decision will be right for YOU. Take care - PJH

Judy

2/10/12 11:51pm

That's exactly what I'll do. In fact, it makes so much sense, I'm embarrassed I didn't think of it myself. :)

PJ Hamel, Health Guide

2/11/12 6:17am

Well, let's just say you're a bit preoccupied at the moment, Judy... It takes awhile, but it all sinks in. Life goes on, it really does, and we go with it. Be well- PJH

Judy

2/19/12 1:23pm

I've seen my surgeon and have had genetic testing, scheduled an MRI, and plan on having a lumpectomy with radiation. In the meantime, I've got increasing pain that I think may be related to the biopsy.

Friday, I noticed that when I raised my arm over my head, I had pain just beneath my right ribcage. I've had a terrible cough, and a couple of weeks ago it got so bad that I pulled a muscle in my back. At the time I felt the pain, I thought I must have just pulled another muscle; that's kind of what it felt like. Since Friday, the pain has gotten worse and has moved up over my ribcage in a line toward the biopsy site. It's also moved down into my abdomen. I can feel something under the skin in a line over the painful area. It feels like a tightly pulled cord running from my breast, over the ribcage, and into my abdomen. It's even visible. I don't know how much bruising is typical after a stereotactic biopsy, but my entire lower breast has been black, blue, purple, green and pretty much any other color you could imagine. There is a knot at the biopsy site, but when I saw my surgeon she gave me a physical examination and didn't say anything about it. Is this a hematoma? Could it be related to the pulled muscle sensation and the palpable cord-like feeling?

I'll be calling someone tomorrow, but thought maybe someone could tell me what this is. And I'm really not even sure to call? The radiology center where I had the biopsy done? My regular doctor? My surgeon?

PJ Hamel, Health Guide

2/19/12 2:08pm

Judy, we're not doctors here, and this is definitely something that needs diagnosis by a doctor; I couldn't tell you if this is related to a hematoma. Generally speaking, you should go back to the doctor/place that "worked" on the area that's causing you pain; so I'd first call the radiology center. If they brush you off, then call your PCP for advice about what to do. However, with severe bruising and, especially, increasing pain, I'd think the radiology center would want to take a look and see what's up - especially since they have lots of experience with biopsies, and would be more likely than anyone else to know what's going on. Also, if the pain and swelling continue to worsen, you might want to consider a trip to the ER, just in case. I hope you can get some help with this tomorrow - PJH

Judy

2/19/12 2:18pm

Calling the radiology center was what I had thought made the most sense but I wasn't sure; that's what I'll do.

Thanks once again for your helpful reply.

PJ Hamel, Health Guide

2/19/12 2:23pm

I remember so well what you're going through, Judy - the pain, the uncertainty, the confusion... Trust me, it DOES get better. Time heals; life goes on. You'll get there, and in the meantime - we're here for you. Peace- PJH

Phyllis Johnson, Health Guide

2/19/12 2:23pm

Although it can take a while for the bruising and knots from a biopsy to resolve; in general, you should be seeing gradual improvement. The cough probably wouldn't be biopsy related, but coughing could pull on your stitches and cause the pain you describe. There is a breast issue called Mondor's cording or Mondor's syndrome in which a blood vessel becomes inflammed. The trauma from your biopsy could cause this condition, which is not usually considered dangerous. If the pain is severe or if you are running a fever, don't wait until tomorrow to call the doctor. If the cough is your main concern, call your primary care doctor. If you are worried about the cording and bruising, call the surgeon. I hope you are feeling better soon.

Judy

2/19/12 2:47pm

Thank you Phyllis. After googling all morning, I'd just run across some sites discussing Mondor's disease before reading your reply and it sounds exactly like what I have. I feel comfortable waiting until tomorrow and am going to apply a little heat to see if it helps with the pain in the meantime. I appreciate your taking the time to reply!

Q: DCIS - please help with pathology report

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