- Question from Nancy: Here are the results of my path report after mastectomy: "2 foci of invasive ductal carcinoma, histologic grade 3/3, nuclear grade 2/3, measuring 0.4 cm and 0.2 cm. Nipple - Paget's disease. Vascular invasion is identified." Could you translate? What should follow?
Beth Baughman DuPree, M.D., F.A.C.S.
In this particular pathology report, there are many things happening at once. Paget's disease is typically diagnosed from changes that we see superficially in the nipple complex that lets us know that there are cancer cells within the ducts below the nipple. What the pathology report specifically tells us is that there are two cancers that were growing at the same time. And although they are graded differently, we use the higher grade cancer which in this case would be 3/3 as our determining guide for further treatment.
The vascular invasion is when cancer cells are found in the small blood vessels inside the breast. It is a associated with an increased risk of recurrence. If this is on your pathology report, your doctor will consider this along with all of the other findings, as the role for further treatment such as radiation, chemotherapy or hormonal therapy is evaluated. In addition, the estrogen and progesterone receptors, and HER2 status should be determined for these tumors, as noted previously in this program.
For those who do not know what Paget's disease looks like, it can begin as a very subtle change in the skin surrounding the nipple and areola complex. It can range from a dry skin appearance to an open sore that gets bloody or produces a clear discharge. This can look like a skin erosion or ulcer.
- Marisa Weiss, M.D. If we see a patient who has Paget's disease plus other changes by physical exam or mammography that are suspicious for significant extension of cancer, then an MRI scan of the breast may be ordered. That test can help us better understand the extent of the disease in the breast. It can help us figure out if there is spread from the nipple back into the central area of the breast. It can help us know if the other areas are separate or connected. Having the benefit of information like this before deciding on surgery can be useful.
Beth Baughman DuPree, M.D., F.A.C.S.
When performing any biopsy of the breast, it is very important that I tell the pathologist in my operative report exactly where the tissue came from in the breast. I also need to describe the orientation of the tissue exactly as I have removed it from the breast. By orientation I mean the three-dimensional place that the tissue was residing in the breast, relative to the front margin (anterior), back margin (posterior), top margin (superior), bottom margin (inferior), inside margin (medial) and outside margin (lateral).
When the pathologist knows what areas may have margins that are close or positive with tumor cells, that helps me to figure out what specific areas may need re-excision after a lumpectomy. In communicating this information, the pathologist can determine the extent of the disease within the ductal system of the breast.
The Ask-the-Expert Online Conference called Your Operative and Pathology Reports featured Beth Baughman Dupree, M.D., F.A.C.S. and Ann Ainsworth, M.D. answering your questions about details of pathology and operative reports and the importance of discussing them with your doctors.
Editor's Note: This conference took place in November 2004.
The materials presented in these conferences do not necessarily reflect the views of Breastcancer.org. A qualified healthcare professional should be consulted before using any therapeutic product or regimen discussed. All readers should verify all information and data before employing any therapies described here.
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