Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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Breast Cancer

  • The Guide to intimacy after cancer, HERE.
  • Tips, pearls, and rules-of-thumb  "cheat sheet"
  • Overview:  overview  types of specimens obtained for diagnosis, and a brief note  about Lexington Medical Center's "5-day Detection to Diagnosis"  program...one of the most personalized breast programs in the USA  [check it out]; for pathologists: how we handle the anatomical pathology for our above program.
  • Magee Risk Calculator: HERE. This calculator uses tumor size, the 9-point scoring system for grade, Ki67 percentage, and quantitated ER, PR, and Heu-2. All of these can be gotten off of a very well done pathology report.
  • young age group: in our program, from 2005-2008, we had 757 cases & 31 were age 35 or younger!
  • About standardizing breast pathology exams and reports.
  • Positive or negative surgical margins, January 2013 Am. Soc. of Breast Surgeons position paper HERE.
  • Nomogram (computerized decision programs) sites:
    • breast: treatment factors and "how to" discussion of how to decide among choices of early stage breast cancer treatments [@ Mayo Clinic; click on "programs and tools"...then scroll down to Health Decision Guides" and click on "early stage breast cancer".
    • breast: how much advantage will adjuvant (a "pre-emptive strike" against possible cells still in your body) chemotherapy give...Mayo Clinic nomogram calculator (you must put your age, number of positive lymph nodes, and maximum tumor size in the formula) by clicking on "programs and tools"...then scroll down to Health Decision Guides" and click on "adjuvant therapy for breast cancer".
    • breast: how much advantage will adjuvant (a "pre-emptive strike" against possible cells still in your body) chemotherapy give...Adjuvant!online...free registration and online use.
    • breast: decision tool at MSKCC to predict pre-surgical likelihood cancer has spread to axillary lymph nodes.
  • Note file on "immuno" (IHC) tissue molecular stains in breast cancer.
  • Note file on serum & tissue markers: [CA27.29/CA15.3].....[HER-2/neu].
  • Note file on FNA cytopatholgy.
  • Note file on benign breast tumors or masses.
  • Grading non-cancer, "premalignant" breast epithelial proliferations: ductal (DIN) and  lobular (LIN) neoplasia and microglandular adenosis (MGA) ; and cancer-associated ADH & CCH. And, see below.
  • Note file on non-invasive breast cancer.
  • Note file on invasive breast cancer types.
  • Risk calculations for chances of getting breast cancer:
  • Factoring in your other health problems: your doctors must consider diabetes, heart conditions, tendency to form blood clots, etc., as they decide the risks of treatments. There are electronic calculators (such as the Charlson comorbidity index...CCI) to help in this [online calculator].
  • Grading  CIS and/or Invasive Breast CANCER (how bad is it?):          
    • Elston-Ellis modification of Scarff-Bloom-Richardson (S-B-R) grading system (Nottingham combined histological grade)  for invasive ductal adenocarcinoma (IDC) [check it out].
    • LeDoussal's modified S-B-R system (MSBR) for invasive ductal adenocarcinoma (IDC) [check it out].
    • grading invasive lobular cancer (ILC) [check it out].
    • Bloom-Richardson nuclear grading system for non-invasive ductal-CIS (d-CIS) [check it out].
    • Lagios nuclear grading system non-invasive ductal-CIS (d-CIS) [check it out].
    • Van Nuys grouping system for non-invasive ductal-CIS (d-CIS) [check it out].
    • Armed Forces Institute of Pathology (AFIP) system for non-invasive ductal-CIS (d-CIS).
  • IHC/ISH/serum markers: proper 10% NB formalin fixation is critical to accuracy & reproducibility; >6 hr but aim for no more than 48.
    • estrogen receptor (ER): alcohol fixative contact prior to formalin fixation blunts positive nuclear IHC marking. Quantitation has two parameters: percentage of nuclei stained & average intensity of nuclear staining. (1) One can calculate % manually or use a computer assisting instrument such as VIAS to "count" the percentage of "positive nuclei". (2) Then one can quickly "eyeball" assess for average intensity of mild, moderate or strong marking.
    • Heading toward greater (but not clinically definitely relevant) greater precision, there is nearly always a range of 1-3+ intensity which we may have to "average" (I have even used fractions such as 1.8+) into the various scoring models. And (1) one can grade the intensity with words (weak to moderate to strong staining of nuclei...such as, "strong 95% positive"; 1-100 H score is "weak", 101-200 is moderate, & 201-300 is strong ) or (2) render a score that considers intensity & percentage of nuclei positive with such as a "quick score", "Q score", "H score", or an Allred score (AS), or even a more casual approach (just let your report be clear as to how you did it). For a "how to" of "eyeball", "H score", "Q score", "Quick score", "Allred score", etc. = HERE).

    • progesterone receptor (PR): same approach as ER, above.
    • Ki67 proliferation: the percentage positivity drops with delay in fixation, & alcohol fixative contact prior to formalin fixation may blunt nuclear IHC marking; expect tubular ca. & classical nuclear grade 1 ILC to be 10% or less; expect "triple negative" to be 50-90% (if not, may not be "basal-like") & expect grade III IDC to be over 25%.
    • HER-2 membrane product: fixation delays cause false positive IHC marking; check concordance by seeing what your IHC does with normal internal control duct epithelium (not to "normalize" but to help evaluate whether any "overstaining" by the IHC process); expect negativity in tubular ca. and positivity in invasive micropapillary. HER-2 page & details HERE.
    • concordance: assessment: one expects ER positivity in tubular & grade I-II IDC, ILC; ER negativity in pleomorphic ILC, medullary ca., invasive micropapillary ca., and basal-like "triple negative" ca. (which should have very high Ki67). Some grade II IDCs can have normal Ki67 (B13-201).
    • serum markers: circulating HER-2, ca125, & ca19.
  • Staging Breast Cancer [ How far has it gone already?]:
    • Finding the lymph nodes:
    • TNM Staging: staging criteria 5th & 6th editions...for all invasive malignancies (AJCC/TNM) [check it out].
    • For ductal-CIS (Van Nuys Prognostic Index...VNPI)  [check it out]; The USC/VNPI is a new modification (scores 4-12) which takes age into consideration. 
    • Calculate your VNPI for noninvasive (CIS) cancer [go do it].
    • KATS  risk grouping predictive for lymph node metastasis...is node sampling needed [check it]?
    • imaging studies: nuclear medicine bone scans, CT's ("cat" scans), MRI, FEG, or PET scans to detect bone, node, liver, lung, brain metastases.
    • blood tests: for cancer antigen (Ag) levels...either CA15-3 or CA27.29 (they are nearly the same...two different instrument companies and two different detection reagents) and LDH (pretreatment LDH elevations may mean proliferating cancer with necrosis).
    • sentinel lymph node (SLN) biopsy issues & Is completion (your SLN was positive) node dissection needed?...decision tool at MSKCC to predict likelihood cancer has spread to other axillary lymph nodes beyond the sentinel node (therefore, go for more).
    • special blood tests: peripheral blood CTCs (circulating tumor cells).
  • What about chemotherapy? Must I have it?
    • Rule (from a May 2000 Dutch journal article ): "The criterion for choosing adjuvant systemic chemo for the individual is an expected increase in 10-year survival of 5% or more."
    • the Mitotic Activity Index (MAI) [need not know lymph node status] [check it out]...your pathologist must specifically measure it if it is to be valid, & this is not a usual determination in a routine pathology report.
    • the Nottingham Prognostic Index (NPI) [must know lymph node status] [calculate it]...your pathologist must specifically measure it if it is to be valid & this is not a usual determination in a routine pathology report.
    • the Morphometric Prognostic Index (MPI) [must know lymph node status] [check it out] your pathologist must specifically measure it if it is to be valid & this is not a usual determination in a routine pathology report.
    • Cummings Prognostic Index (CPI) [need only know node status & grade...for occult node cases]: [check it out]...your pathologist must specifically measure it if it is to be valid & this is not a usual determination in a routine pathology report.
    • Uniformed Services University of the Health Sciences: cases were more likely to get cytotoxic chemotherapy if S-phase fraction elevated [if proliferation marker of any type...such as Ki67...is really elevated?] (Am. Surg. 63[4]:330-333, 1997).
    • Genomic testing of the cancer: this began in 2004 and by March 2005, the "grind and bind" oncotype DX $3400 test had been done on about 5 cases in our program. There are limitations.
    • On-line riskiness or prognostic calculator simulating genomic portrayal but using H&E and IHC: we can use the NPI, the (Pittsburgh) morphological Magee on-line equations [HERE], and common sense (all based on case-specific intent & meticulous dissection and observation) for a case-specific comment in the pathology report of the completely excised cancer and sentinel nodes, HERE.
    • Bone marrow (BM) for cancer cells: though we don't see this test performed in our area, Dr. Richard Cote & others showed that further stratification of axillary node negative patients...(1) those with cancer cells in BM and (2) those without...helped [those with cancer cells relapsed & are certainly chemo candidates].
    • Axillary lymph node immune cell status: Dr. Peter Lee @ Stanford has recently shown that testing the nodes for T4, T8, and dendritic cells gives a powerful prediction for or against relapse...a help in decision making.
    • St. Gallen 2001 risk strata for node negative patients:
      • low risk (may not need chemo) are grade I, ER and/or PR positive, not greater than 2.0CM in size, and in patients aged 35 or higher.
      • High risk are grade II or III, ER & PR negative, larger than 2.0CM and in patients younger than 35.
  • Plastic surgery: Aside from such surgery for cosmetic reasons, there are instances of plastic surgery techniques to remove residual margin-positive lumpectomy areas with cosmesis and viability optimized. And, there are instances of oncoplastic reduction mammoplasty in order to optimize radiation therapy [L14-7262].
  • National Comprehensive Cancer Network (NCCN) Practice Guidelines for treatment options: go to the general web site and choose "patient options". For your particular, personal case choices, you will need to know the cancer stage that your doctors believe you are currently in. Then you can see what the consensus scientific primary/initial treatment options are for that stage. Remember that your particular case may have a mitigating or complicating factor or two which would further modify these general recommendations [check it].
  • National Accreditation Program for Breast Centers (NAPBC): The LMC program became NAPBC accredited in the summer of 2010. NAPBC = HERE.

Ref.

  1. Cuzick 2011 IHC4 Score, HERE.

(posted Jan. 2001; latest addition 10 December 2015)

 
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