A question for Beesie

Ductal Carcinoma In-Situ
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A question for Beesie

Postby camsdh » 22pm28America/New_York()

Bessie, how close is this.
Also I will message you on this site with a file I would like for you to look at and give me your opinion if you would like.


How DCIS becomes Invasive while stile having DCIS...If one has well differentiated DCIS and as the cells devide..some cells are mutated, a division of one defined DCIS cell and one poorly defined DCIS cell. Normally (60% of time) the body's immune system will "kill" the few mutated cells. If the host has a glitch in their genes.. over or under experession of p53, COX, cadrena,(sp) ect. these mutated or poorly differentiated DCIS cells "home" and then compete for dominance with the more stable well differentiated DCIS cells. The poorly differentiated cells become Invasive seperately from the other DCIS. The glitch in the genes then decides the type or grade of invasive breast cancer. Thus a path report of IDC and DCIS.

I got this from the following paragraph: Am I understanding it correctly

Conclusions: These results strongly support the hypothesis that poorly differentiated DCIS gradually evolve from well differentiated DCIS by randomly acquiring genetic defects resulting in increasingly abnormal cellular features, that this diversity is amplified by defects resulting in genetic instability (e.g., p53 mutation), and that the alterations are propagated to IBC independent of progression to invasion.
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Re: A question for Beesie

Postby Beesie » 22pm28America/New_York()

Interesting! Reading that paragraph, I come to the same conclusion that you do.

There is just so much that medical science doesn't understand yet about why and how DCIS becomes invasive. The focus of science in this area tends to be on cases of pure DCIS - what will cause pure DCIS to at some point become invasive? For some reason (one that is totally beyond me), little has been studied about cases where the DCIS has already progressed to become IDC. DCIS with a microinvasion of IDC is a very common diagnosis (mine, for example). Usually microinvasions of IDC are found in situations where women have large amounts of high grade DCIS. In these cases it's simply believed that the DCIS cancer cells multiply within the milk duct and then at some point, one of these highly aggressive (grade 3, comedonecrosis) cancer cells breaks through the milk duct to become IDC. And that's that.

However, while it's generally been found that low grade (i.e. well differentiated) DCIS is less likely to become invasive, there certainly are cases where women with just a small amount of low grade DCIS are found to have invasive cancer as well. What causes that?

And how do we explain all the women who have IDC (or IBC or ILC) along with a small amount of DCIS? IDC with some DCIS is actually a very common IDC diagnosis. When looking at the progression of DCIS to IDC, these cases aren't considered because these cases 'start out' as IDC. But if DCIS is also present, did these cases really start out as IDC or did the cancer in these cases actually start as DCIS? If so, what caused the DCIS to convert so quickly to become IDC, to the point that the IDC took over from the DCIS?

Why do some women have lots of DCIS and no IDC while other women have lots of DCIS with a small amount of IDC and others have lots of IDC with a small amount of DCIS? What are the pathological differences that cause these different diagnoses?

As for IBC, there is virtually nothing written about any connection between DCIS and IBC. But does this mean that IBC doesn't sometimes source from DCIS? Not necessarily; it could just mean that there isn't enough scientific evidence about this yet, both because DCIS has not been well studied and because IBC is relatively rare.

Lots to learn!
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Re: A question for Beesie

Postby camsdh » 22pm28America/New_York()

Beesie
I can't attach the file I wanted you to read. I will try to find a different way to get it to you.

Once when I said I was a friend of Dr George Peters you said interesting...why?
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Re: A question for Beesie

Postby Beesie » 22pm28America/New_York()

I am fascinated by the whole "lumpectomy vs mastectomy" discussion and Dr. Peters was one of the leaders in promoting that the lumpectomy + radiation approach so that interests me. It's also interesting that you know him, given that you are now so personally affected by breast cancer. Funny how life works that way, sometimes.
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Re: A question for Beesie

Postby camsdh » 22pm28America/New_York()

I do not just know him, we were best friends growing up. He over at my house, me over at his. He's greek, and I loved the family life he had. His mother died or cancer when he was just a boy. That's when he decided to be a doctor. His dad had a little neighborhood store is a poor part of town. When we graduated from high school, George went to Ole Miss, because of the med school, I went to MS State for the engineering school. I did room with his cousin at State, so George was over offen. When he graduated college, though he was at the top of his class, he was refused by the Med School.. That was the 60's in MS, so even Greeks was discriminated against.. He did not let it bother him, he was such a good student they made him an anadomy professor and let him in the next year. He is a truly great guy. Just, that now, his mind is very damaged and stays under managed care.
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Re: A question for Beesie

Postby Emerald » 22pm28America/New_York()

Wow reading all that it seems like it would be so difficult to have DCIS turn into IDC, but that is exactly what happened to me. My surgeon just explained it by saying the cancer cells "busted" through. Did you guys look in the site at the info I posted an the pics about how DCIS becomes invasive?

Lumpectomy vs. mastectomy is a huge decision to make. Many women struggle with it, I however said "cut 'em off" I didnt have hardly any "real ones" anyway, just implants...... :)

But I did have lumpectomy first, dirty margins. He took out area of over 5cm and cancer cells were <1mm from edges. Since I had so little breast tissue, that put the cells against my skin and chest wall. I did prophylactic on right side as I didnt want to worry about it and I want to be even and I couldnt stand to see one babd one good in mirror..... :o
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Re: A question for Beesie

Postby Beesie » 23pm28America/New_York()

Wow, how unfortunate that Dr. Peters isn't well. That's a loss to the breast cancer community and I'm sure to you as well, as his friend.

Emerald, I looked at what's been posted about DCIS and I'm confused by it. In your previous post, are you referring to the pics that show Cancerous IDC with DCIS microcalcifications? Or are there other pictures that I've missed? My concern about the DCIS microcalc picture is that there is no mention of the fact that most microcalcs - over 90%- are harmless and are not DCIS. I wouldn't want anyone with microcalcs to think that they are certain to have DCIS when in fact they are much more likely not to. So if this is the only reference to microcalcs (and it's the only one I've found so far), this could be a problem.

I also looked at the chart about how the characteristics of DCIS impact the rate of recurrence and the likelihood of invasiveness. This is probably the area that I've researched the most in the 3+ years since I was diagnosed so I'm pretty familiar with the data on this but I don't understand the chart at all. From everything I've read - and that's a lot ;) - the risk of low grade eventually becoming invasive is probably in the range of 10% - 25%. But the risk of high grade DCIS and/or DCIS with comedo necrosis becoming invasive is much higher - it's hard to get any experts to venture a guess but the range is probably 50% - 95%. The chart that's posted about DCIS suggests that the risk of invasiveness from high grade DCIS is only 11.8%. If you consider that upon viewing the final pathology, approx. 13% of women initially diagnosed with DCIS are found to have IDC as well (either a microinvasion or more), that suggests that the starting point for the risk of invasiveness, the low end, is 13% (and that assumes that no other cases of DCIS would ever become invasive). It's also believed that 80% of IDC cases started as DCIS, so here again that would suggest that a high percent of DCIS cases do evolve to become invasive. Lastly, if someone with DCIS has a recurrence, in 50% of cases, the recurrence will be in the form of IDC. These are women whose primary DCIS was removed and treated and yet their recurrences were IDC. So that too suggests that the risk of invasiveness is much higher (imagine what % would have become invasive if the DCIS had not been removed and treated).

As for risk of recurrence, the biggest factor is margins, followed by grade, followed by amount of DCIS found. The three factors need to be combined to get a realistic picture of recurrence risk. Someone with wide margins on a small amount of low grade DCIS might have only a 4% recurrence risk. But someone with small margins on a large amount of high grade DCIS will have a recurrence risk of more than 30% and possibly as high as 60%. The chart that's posted suggests that the greatest risk of recurrence is 17.1%, for high grade DCIS.

Sorry for rambling on all this. It's one of my personal hot-buttons! (But I'm sure you probably figured that out by now. :roll: )
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Re: A question for Beesie

Postby camsdh » 23pm28America/New_York()

Ductal carcinoma in situ (DCIS) is the fastest growing subtype of breast cancer, mainly because of the aging of our populations and improvements in diagnostic mammography and core biopsy. DCIS represents a proliferation of malignant-appearing cells that have not invaded beyond the ductal basement membrane and is a precursor for the development of invasive breast cancer (IBC). Approximately 40% of patients with DCIS treated with biopsy alone, without complete excision or further therapy, develop IBC. Most DCIS itself is harmless if it is detected and excised before it can progress to IBC, and the current approach to DCIS treatment is aimed at just that goal. Typically, it consists of multimodal treatment including segmental mastectomy followed by radiation therapy to the whole breast and then hormonal therapy or total mastectomy followed by hormonal therapy.

This review discusses the state-of-the-art in DCIS detection and treatment and highlights promising new strategies in the care of DCIS patients. The data regarding the effectiveness of breast-conserving surgery versus total mastectomy, the possible avoidance of radiation therapy in some subgroups of patients, and the role of hormonal agents are reviewed. Neoadjuvant therapy and the use of trastuzumab for DCIS are currently under investigation and may be future treatment options for DCIS.


See full article at
http://theoncologist.alphamedpress.org/ ... 12/11/1276
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Re: A question for Beesie

Postby GingerSnap » 24pm28America/New_York()

I had both DCIS and IDC .. with necrosis. I remember being confused at reading in situ... kept hoping that I was misreading that I also had IDC. I learned, like Moody, that it busted through. Waiting til 42 to have a first mammo was not smart, should of had it at 40!! But so many women are told 42 is safe to have their first one if there is no family history. Thankfully, I found my lump before I had even scheduled my mammo.
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Re: A question for Beesie

Postby Beesie » 24pm28America/New_York()

Ah, The Oncologist article is one of my favorite reference articles about DCIS; it's quite current and it covers a lot of ground.

I've actually taken the time to read most of the studies that are the sources of the data in this article. What's particularly interesting to me is that in reading the study that is the source of the statement "Approximately 40% of patients with DCIS treated with biopsy alone, without complete excision or further therapy, develop IBC.", it turns out that they were looking specifically at women who had "small, noncomedo DCIS". That actually makes sense, since very few women with large, high grade or comedo DCIS would agree to just a biopsy alone without excision of the rest of the DCIS. And as the source article says, a conclusion about small noncomedo DCIS is "quite different from the natural history of comedo DCIS".

So this takes me back to my earlier question about the chart that's included in the other section of the board, which shows the risk of invasive cancer to be only 11.8% for high grade DCIS. If the article from The Oncologist is saying that the risk of invasion is 40% for those with small, noncomedo DCIS, then obviously the risk of invasion for those who have larger and/or high grade and/or comedo DCIS is much higher. My personal estimate of 50% - 95% sources from dozens of articles & studies that I've read. Truth is that I actually doubt that the risk could possibly be as low as 50%.

I think the most important message about DCIS is that each case is unique. I wouldn't want anyone who has a small amount of low grade DCIS to worry unnecessarily about her future risk. I'm always sad when I see those with that type of a diagnosis overly scared, and when I see them overtreat their disease. On the other hand, I wouldn't want someone who has a large amount of comedo DCIS to think that she has nothing to worry about, and as a result, to undertreat her disease. In each case these women may have the same top-line diagnosis, DCIS, but they have very different pathologies, very different future risk levels and as a result, they may require different treatments (lumpectomy vs mastectomy, radiation or not, hormone therapy or not).

With DCIS, one treatment regime does not fit all!
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Re: A question for Beesie

Postby Beesie » 24pm28America/New_York()

By the way, I had DCIS with IDC too. Fortunately for me, the IDC was just a microinvasion, but that's enough to change the staging from Stage 0 to Stage I. So just looking at those of us here, it's easy to see that the risk of invasion from DCIS is actually pretty high.

The really interesting thing to consider is that because the 3 of us were not Stage 0, we are not included in any of the stats that talk about the "risk of invasion" for someone who has DCIS, even though our cancer started as DCIS and then broke through the duct to become IDC. How dumb is that?
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Re: A question for Beesie

Postby GingerSnap » 24pm28America/New_York()

Yeah, really dumb!!!!!!!

Ok, what is the difference between IBC and IDC?
I know IDC is Invasive Ductal Cancer
is IBC Invasive Breast Cancer???? Which would then include all types of cancer that has invaded??
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Re: A question for Beesie

Postby Pat » 24pm28America/New_York()

IBC is Inflammatory Breast Cancer. It presents very differently than more "typical" forms. There is a good explaination of it under Cancer Corner - Less Common on the Breastcanswers Home Page.
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Re: A question for Beesie

Postby GingerSnap » 24pm28America/New_York()

oh duh! That's what Cam has.
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Re: A question for Beesie

Postby Beesie » 24pm28America/New_York()

IBC is Inflammatory Breast Cancer but just to confuse things, a lot of articles also used the abbreviation IBC to refer to "invasive (or infiltrating) breast cancer". So you have to read into the article a bit to see if they are referring to Inflammatory BC or invasive breast cancer.

I had thought that it was mostly a British or European thing to use IBC to represent invasive BC but recently I've found a number of American articles that also use IBC this way. Here's one, which is also interesting in that it talks about DCIS progression to IBC (invasive BC, that is, not Inflammatory BC): "CONCLUSIONS: Results indicate that DCIS diagnoses reduce future IBC diagnoses. This suggests that the natural history of DCIS is progression to IBC at high rates within two to five years. Because recurrence rates following treatment of DCIS are low, the detection of DCIS prevents many cases of invasive breast cancer. " http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=103625073.html

And yes, IBC (invasive BC) refers to all invasive breast cancers, IDC, IBC (inflammatory BC), ILC, Medullary BC, etc..
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Re: A question for Beesie

Postby camsdh » 25am28America/New_York()

Other than that one question on a math test back on Jan 22, 1974, Bessie is always right. IBC when mentioned in any article about DCIS is used for invasive breast cancer, not inflammatory breast cancer. I have spent the past year looking for someone to say in words, DCIS can morph/change/evolve whatever to Inflammatory. Since Cam's path was nc Dcis, IDC, with dermal lymphatic invasion, i am sure this was the case with her. IBC is confusing..aggresive and rapidly developing IDC with skin involvement is IBC(can be ILC 10% of time) slower growing IDC with break through to skin is not IBC. This is just one of the many reasons that IBC is not well dx, even the med prof. have a great deal of trouble defining it. The new rule proposed will change it from a clinical dx (BC with Inflammatory signs) to a path dx (Tumor emboli blocking dermal lymphatic chanels). There are markers that are overexpressed with IBC, but are not tested for dx, just tested for research. (looking forward to spell check)
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Re: A question for Beesie

Postby Beesie » 25pm28America/New_York()

Geez, even you know about that mistake on my math test back in 1974?? I run but I can't hide from it. Someone always finds out. And now the world knows!

Seriously though, I'm certainly not always right. It's just that I've been around this DCIS and DCIS w/ microinvasion thing for over 3 years now, so it's one topic on which I'm reasonally well informed. Being a research junkie helps too. The problem of course is that in this field there are always new studies coming out so it's impossible to be up-to-date and to know everything that's out there. And just to make things interesting, the new studies don't always agree with the previous studies. Figuring out DCIS (or at least, the current medical beliefs about DCIS) is like trying to pin jello to the wall.

I suspect that it's probably even harder with IBC (inflammatory, that is).
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Re: A question for Beesie

Postby VoiceOfReason » 02pm31America/New_York()

Does the study you are getting the info. from in this post distinguist women who have had a lympectomy and women who have had a mast?? I would think that would make a huge difference in reoccurance

By the way, just as your friend..you have gained a little bit of weight since you moved to this new site.
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Re: A question for Beesie

Postby kmccraw423 » 06pm31America/New_York()

Your avatar has certainly gained weight Beesie!

While I was in the hospital to have the expanders removed (infection) I asked my Primary Care Doc what would happen had I done nothing about DCIS. He said "they don't know." It seems to me that it becomes invasive. Am I reading that right?

I had double mastectomy - I was not about the play with cancer.

What if you did nothing about treating DCIS? Would anything happen or are you just playing Russian roulette?
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Re: A question for Beesie

Postby Emerald » 06pm31America/New_York()

Beesie, I dont know which part of the pic on the website is IDC and which is DCIS, but what I do know, these pics are of my b/c :| and that is what I was diagnosed with.

My path report read:

    "Invasive ductal carcinoma, tumor size 1.3cm, Nottingham grade 2.
    "Carcinoma extends into adjacent lobules."
    "High-grade ductal carcinoma in situ, solid and cribriform pattern. Specimen size 5.0cm x 3.1cm x 1.1cm."
    "Lateral and posterior margins are involved by ductal carcinoma in situ with less than 1mm extension."
    Margins are uninvolved by invasive carcinoma with distance to margins no closer than the in situ component."


So, that be's how I know. Bummer :(
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