Black's Nuclear Grade 3 § additional questions

[millerpuryear]

My mother had stereotactic core bx on 3/13.  Diagnosis was DCIS, comedo type with prominent microcalcifications, One smal focus suspicious for possible invasion (in left breast);  right breast wasnegative for ductal and lobular hyperplasia.  Pathology noted that "tumor cells demonstrate Modified black's nuclear grade 2 features....the area of possible invasion measures less than 0.1cm"

She had a lumpectomy on 4/4.  final diagnosis: left breast mass: multiple foci intraductal carcinoma, solid and cribriform patterns (CDIS), Modified Black's nuclear grade 3; lesion estimated 3.5cm with foci of intraductal carcinoma extending inferior, medial, lateral and superior margins of resection.

Originally the doctor opined that my mother would need only the lumpectomy and possible radiation.  She said this was nearly 100% cure.  At this time (pathology from 4/4 was received on 4/11) doctor recommends simple mastectomy (both breasts) with sentinal node removal.

Is the modified black nuclear grade the same terminology used when referring to the 'grade' of cancer?  Why would it appear as a 2 just two weeks prior to being graded as 3?

All the medical lingo is confusing.  We can understand DCIS and understand the recommendation for Mastectomy.  What does the nuclear grade suggest?  Why does doctor recommend bilateral mastectomy if there has been no tissue specimen with cancer cells from the right breast?  

Is the nuclear grade subjective or objective? What is the prognosis? Thank you for your time.

[CCF-RN,MSN-JS]

Dear millerpuryear, Nuclear grade refers to the growth rate of the cell and how odd-looking the nucleus of the cell is.  Pathologists usually grade on a scale of 1-3 or 1-4, with a higher number being worse.  When talking about grade alone they are looking at different features of a cell (such as size, shape, activity of the cell) that are combined together to give an overall score that is then translated into a grade.  There is some degree of subjectivity to the interpretation of the cells by the pathologist.  However after the lumpectomy there was more tissue which could explain the different nuclear grade of cancer.

Also noted from the above is the intraductal carcinoma means there is an invasive component, this finding will be what is concentrated on in terms of treatment etc.  At this point because there not being clear margins after the lumpectomy further surgery would be recommended.  If lymphnodes have not been removed, a lymph node dissection which removes lymph nodes for examination in the fat pad under the arm.  

Based on the above information, I don't know why a mastectomy would be recommended for the right breast.  

At this point more information is needed, such as lymph node status, before the stage of your mother's cancer is known.  This information is used to determine recommendations for further treatment, treatment is discussed in terms of risks (side effects) and benefits (decrease in recurrence rates and survival rates).

[surgeon]

Actually, what you stated in the pathology report does not indicate an invasive component. I think the recommendation for mastectomy is because the tumor cells are extensive within the breast, which has a high recurrance if treated by lumpectomy/radiation, especially with the comedo type. However, cure rate is still extremely high. Because microinvasion is possible even when not seen so far, it's not unusual to check a lymph node at the time. As to the opposite breast; it's not carved in stone: but when there's that extensive disease on one side, the chance of developing it on the other is fairly high. So the choice is to eliminate that risk by "prophylactic" mastectomy, versus watching carefully. It's an area for personal choice: some women would sleep easier not worrying about it. Others would be happier not doing anything unless something showed up; hopefully if it did, it would be non-invasive as it is on this side.