ABNORMALITY IN MY BREAST
***give me your
comments about this page***
SHOCKING STRESS! [a 9/22/2015 NPR Fresh Air layman's update pod cast, HERE & starts at 1:40]
While the sobering news that
you might have breast cancer does not constitute an actual
medical emergency, a high percentage of women state that the period "of not
knowing the answer" was the single most stressful event/interval in their entire lives!
Understanding this "emotional emergency", beginning in 1987 as incisional & excisional biopsy became accepted, the surgeon's need to see the patient 48 hours later to remove the drain prompted our surgeon
colleague, Dr. Curtis McGown, to request that we institute a goal of faxing the pathology diagnosis to the
surgeon's office the next weekday after we received the tissue specimen. Since 2000, we do the
same with our Breast Center core biopsies. Here are our types of LMC doctors who can help [here] and our Find a Doctor, HERE.
[create your free website to keep loved ones posted on your
The safest course for a woman in avoiding death by breast
cancer is to take charge of her life. Find out about your ancestors so that you can be properly
aware of your risks. [risk
chart]: did any of them have breast cancer? At what age? A couple of
general, on-line risk calculators are: [Harvard online calculation of your personal risk for breast
cancer] or Women's Cancer Network [risk test on-line]. If breast or ovarian cancer has
occurred in your family or families of your mother and /or father, you should be even more
careful (see genetic inf., below)...[check this risk chart]. The earlier it is detected,
the more likely breast cancer can be cured.
FIND IT EARLY
Arguments coming out in 2009 & 2010 suggesting that
society tone down the quest for early detection are STUPID & defy common sense (as to an
individual patient's welfare). The reasoning is akin to issuing a notice that we have been too
demanding in advising people to drive cars using seatbelts because seatbelts mostly sit strapped
harmlessly and are not actually used very often to save lives! Even in the absence of breast cancer
in your family, every woman should perform periodic breast self-examinations (check YouTube
demo HERE). And, beginning at about age 40 (for the average
woman without a family history of breast cancer), a woman should have screening mammography
approximately every year...high family risk persons, earlier. Skilled
mammography is a must (computers can't make up for lack of sufficient skill...see R2,
below)...look for a certified mammography service officially attached to a multidisciplinary
breast program. Depending on the tissue texture of your breasts, ultrasound and/or MRI may be
needed. It is a shameful myth that some small breast cancers actually go away if we'd just leave
them alone & not detect them (as in AARP member magazine of January-February 2010, page 14).
Early detection is NOT a patient-quality problem; under-diagnosis and/or over-treatment could be
a problem. Treatment: Once you have a breast cancer diagnosis, then all treatment options are directed at (1) initial local control, (2) preventing local recurrence, and (3) preventing distant recurrence. Decisions about each of the three rely on precise, accurate information from Radiology, Pathology, and the surgical process.
If I refer to "our program," I mean all of our area
breast-involved doctors and the services available at Lexington Medical Center......[disclaimer, again].....Who am I (this web site author)?
We claim "Five Days Detection to Diagnosis". That is, if you detect or
suspect an abnormality in your or a loved one's breast & call our nurse coordinator, we will
have a pathology diagnosis within 5 work days in a high percentage of cases (our "record" case
is 3 hours, and we average between 2 & 3 days!).
PATIENCE and GETTING THE ANSWER:
Now, suppose you, your husband, your doctor, or the
screening mammogram detects an abnormality: DON'T PANIC! There are a number of
types of non-cancerous abnormalities. If the abnormality was detected by a screening mammogram, it
must usually be further studied by a diagnostic mammogram and/or ultrasound (U/S) exam, maybe even
an MRI. The interpreting radiologist is a physician who is in a position to tell you something
about "how suspicious the abnormality is", if you get an appointment and ask (and, since you will
be billed for the interpretation of the imaging studies by the radiology group, you certainly have
the right to ask questions...just remember that their report...interpretation...is to your
physician; it would not be unreasonable to charge for personal appointment time with you).
Ordinarily, however, the radiologist communicates with your personal physician. In many instances,
certain abnormalities are logically followed for a period of study time in search of any evidence
that it is a changing condition. If your doctor suggests that you so watch and wait and you feel
anxious and contrary to such, let your reservations be clearly known. If need be, you could get an
additional opinion from the radiologist or some other physician. If your health insurance coverage
is by a restrictive HMO or managed care plan, there could be some subtle built-in incentives for
that health care plan to advise you based on well-considered and possibly reasonable cost-saving
(to them) odds of whether your abnormality is cancer or not, rather than on
further procedures. Your doctor, in any case, is likely (in your behalf) to also consider potential
RISK: It is most important that you let your doctor know exactly how YOU feel
about taking any chances. At some point your doctor may decide that the abnormal area needs to be
sampled for a definite diagnosis, possibly even entirely removed as a diagnostic
sample. KEEP in mind that any surgery is rarely likely to have infectious or even deadly pulmonary embolic (blood clot to the lungs [a case B15-57]) consequences. Check out some viewpoint
information about cancer, "cure", etc. in this file for men facing the
prospect of prostate cancer. Here are some of the possible diagnostic tests or types of
sampling and surgery:
FOR YOUR CONVENIENCE
AND EXPEDITIOUSNESS OF BIOPSY, CYTOLOGY, OR IMAGING WORK-UP:
Lexington Medical Center has designed a program which you can plug
into with a single telephone call (800-635-0858 [803-791-2521...Breast Health Services]). You never
lose control of your case, all scheduling hurdles are taken care of for you, and every attempt is
made to minimize waiting and frustrations. We organize everything for you in our system which
brings all specialties into your picture prior to suggesting a plan. It has always been standard
procedure that Lexington Medical Center radiologists and pathologists liberally
consult among themselves (within each specialty group) in day-to-day practice so that your case may
have had multiple opinions considered in arriving at your original working diagnosis. If you prefer
referral to some distant treatment program, help doing so is available. Our goal is to have a firm
diagnosis for you within five working days after your telephone call entering you
into the process. Coordinator: Kelly Jeffcoat, RN (Deirdre Young, RN is still with us but promoted
to a broader responsibility).
We are constantly seeking ways to refine the most
systematically expeditious comprehensive breast diagnosis and treatment program in the southeastern
United States. I have informally surveyed our physicians and found that it almost invariably
becomes a problem leading to your dissatisfaction when you try to get your doctors or our nurse
coordinator to "bend the system" one more notch especially for you. It is exactly because we
understand your worry that we have already developed a positively remarkable system. Help us to
help you by holding tight to your patience. Thank you so much!!!
IF CANCER IS DETECTED...TWO WARNINGS!!
(1) Those of us regularly involved in the diagnosis and treatment of cancer are
highly aware of concerns about cosmetic results. At our weekly multidisciplinary breast
cancer meeting of 24 October 2002, there was an extended discussion that revolved essentially
around this: issues of prioritizing the cure of the cancer are sometimes
being overshadowed by concerns (or preoccupation) about cosmetic choices. I
urge everyone to keep these two important areas of concern clearly in mind as you get into
treatment options and decisions. Breast cancer is a life-threatening cancer, and I believe
that a top priority should first be given to efforts to assure (as much as
possible) cure! (2) "Decision block" is a life threatening mental paralysis in which the
patient shops between treatment programs...confusion results...onset of therapy is delayed.
Don't hesitate to ask about referrals and second opinions if you lack confidence in your
doctors. But it is critical to place your case with someone very soon and
stick with them & their hopefully expeditious guidance. AND, in 2015, it has finally been sort of proven that there is little or no value to chemo for certain breast cancers, as on this Hear & Now podcast.
***By The Way: how
is your spiritual
TYPES OF TESTS & TUMOR SAMPLING
PROCEDURES AT LEXINGTON MEDICAL CENTER:
mammography, film: no tissue sample; standard-view breast x-rays which have no
radiation danger at all; may be uncomfortable because the breast must be flattened somewhat and
include some area toward the arm-pit. Totally benign cases are screened out. The R2
computer screening robot also (in addition to the radiologist) screens the films in search of
microcalcifications (recognized as high intensity pixels...R2 most effective here) and stellate
lesions (recognized as intersecting lines of density). At Lexington Medical Center, women are
doubly protected in screening of both mammograms and Pap smears by the double use of human
experts and computer image scanners.
mammography, digital: we added this improvement in late
- Definitive (rather than screening) diagnostic
mammography, film: no tissue sample. This is often referred to as "return for
additional views". (The diagnostic session may be added to the screening session if both done
in same geographical area.) This step is for those cases which were not screened out as normal.
Because of additional efforts to get exact pictures of a suspicious area, there could be a
little more squeezing and discomfort. Our hospital has this.
- Definitive (rather than screening) diagnostic
mammography, digital: we added this in 2008.
- Digital Breast Tomosynthesis (DBT): this is a high resolution "3D" mammography (HERE) which we added in April 2015, the first in central S. C. to do so. DBT has a decreased rate of false positives.
(U/S) examination, classical diagnostic: usually determines if the palpable or
mammographically detected suspect area is cystic vs. solid; potentially more exact measure of
tumor size; no tissue samples (unless as below). (Sometimes added to diagnostic mammography
session). Is a real-time exam...no waiting for film to develop. When a mammographically
abnormal pattern is suggestive of non-invasive breast cancer, U/S can sometimes "see" areas for
core biopsy sampling which are more likely to be small areas of invasive cancer. The procedure
should be expertly performed with high quality instruments (such as a transducer of 7 megahertz
or higher). It is an error that people such as actress Suzanne Summers tell you to demand
complete U/S exam of both breasts. U/S false positive rate is so high (if both breasts
completely examined) that it is only an adjunct exam focused on a problem detected clinically
or by mammography. Ultrasound is poor in fatty (mostly postmenopausal) breasts because both fat
& cancer are hypo-echoic. It is good also for examining breast tissue which can't be gotten
into the mammogram image. Our hospital has this.
diagnostic elastography: measures the springiness or compressibility of breast tissue
components as the device presses over the breast. Stiff areas show up as dark spots on the
image. Pioneered by Jonathan Ophir in the 1990s, an exciting study of accuracy was reported
Resonance Imaging (MRI): This is for special situations because, though very sensitive to detect cancer but a lot of noncancer stuff shows up "positive" to cause a high false positive rate. Since about April 2002, we have added this modality to our
scope of imaging services. MRI shows excellent anatomic detail of the breast. It is excellent
at detecting occult rupture of an implant capsule. Some are using it in cases of
biopsy-diagnosed breast cancer otherwise suitable for conservative breast surgery (CBS) to give
MRI proof of negativity for suspicious lesions elsewhere in that same breast (however, some
breast-specialist radiologists feel that this use could be less dependable than hoped for...not
enough data yet) and maybe even the other breast. By 2007, more are MRI testing the malignant
breast scheduled for conservative breast surgery. And, MRI may be a way to follow very high
risk individuals who prefer not to have all breast tissue removed (the problem being that MRI
might see "suspicious lesions" which cannot by any other modality be localized for biopsy). Our
hospital has this.
Resonance Spectroscopy (MRS): this scanning modality "reads" whether molecules
attaching to the lesion cause emission of one (benign) or another (cancer) signal. It can tell
whether an area abnormal by other imaging methods is benign or malignant tissue. Our hospital
Electrical Difference Analysis (HEDA) scan: this is an electrical impedance scan
similar to ultrasound except that electrical current applied through the breast skin is used to
detect electrical field variations that allow the detection of small cancers. As of 1/03, we
are involved in an investigational study using this modality. Our hospital has
- Nipple smear
cytology: when a woman has noted drainage or discharge from a nipple, either directly
or as staining of her bra, a smear of a drop of discharge can be made & rapidly placed into
an alcohol fixative (you could even collect a sample of drops each day for a number of days
into a glass containing liquor as the alcohol source) and sent to cytology for diagnosis. Our
hospital has this.
- Open wedge or incisional or excisional diagnostic biopsy: though this was a REAL step forward in 1990, this is now done ONLY in exceptional circumstances due to the smoothness, ease, and acurracy of core biopsies.
- FNA & core biopsies: Often as a doctor's office procedure,
Fine Needle Aspiration is when a thin needle
is inserted into an abnormal area (the area must be easy to feel) and tumor cell clusters
syringe-suctioned out (more or less as "drop" of moisture) and prepared onto slides for a
diagnostic interpretation by a qualified pathologist. A very quick procedure with answer
possibly available same day...if the office sends the specimen to our pathologists (some health
coverages require for full payment that doctor's-office specimens be sent elsewhere) or if our
pathologists perform the procedure. An FNA-like cytology prep can be taken from the breast
center core biopsies as a way to get same-day biopsy if that cytology diagnosis is
unequivocally cancer. Our hospital has this.
aspiration cytology: using a syringe and needle, a breast abnormality containing
fluid can be punctured and the fluid sent for cytology diagnosis (a cytology test, as
with FNA, but FNA smears the moisture from the needle onto slides at the time of the
procedure). Our hospital has this.
- Galactogram...Ductography: a quite uncomfortable study used
to work up cases of bloody nipple discharge from a single duct in a breast with negative
mammography & ultrasound = a thin blunt needle can be gently probed into the opening of the
abnormal duct on the nipple surface. Contrast dye is then injected and mammogram-like X-rays
taken in search of the abnormality and exact location of it. Nipple discharge fluid is
sometimes also sent for cytology diagnosis as with FNA. Our hospital has this. An alternative
is to go straight to diagnostic biopsy [B08-109] where, under anesthesia, the surgeon inserts a
probe into the duct until it meets resistance (butts against the lesion); then it is secured in
place and the abnormal area excised (duct excision).
lavage: Dr. Susan Love and some others have promoted this as a combination breast
cancer screening test and anti-estrogen treatment triage test; it is even promoted at MUSC in
Charleston. A breast pump is placed over the nipple and suction applied. If any fluid
comes out, a thin catheter is inserted (similar to ductography) and saline flushed into the
duct...breast massaged & fluid drawn back out & sent for cytology diagnosis. The idea
is that, if "atypical cells" are found (25% of cases of high-risk but asymptomatic
patients...only 10-25% of which go on to have invasive cancer [75-90% just get scared out of
their wits!]) and studies are negative for cancer, patient (especially the high risk family
patient) is put on anti-estrogen treatment such as Tamoxifen. But, studies using this procedure
on women with known breast cancer already headed for mastectomy showed that less that 50% (only
7 of 15 cases) tested positive...a totally and dangerously unacceptable lack of sensitivity!!
None of our doctors see this procedure as worthy, and it is not done in our
- Thermograhy: though widely available, we believe that this
heat-sensing technique for detecting breast cancer is too insensitive (and too non-specific)
for breast cancer detection. Not in our program.
- Simple, non-imaging, diagnostic & therapeutic lumpectomy: though uncommon now, in 1988 this was an emotion-laden alternative to the old timey (@ LMC 1971-1988) surgical posting for mastectomy if a frozen section diagnosis was cancer. After a Canadian study proved lumpectomy and some sort of lymph node staging was as effective as mastectomy, our surgeons wanted us to ink the lumpectomy margins and state whether the margins were clear or positive. One of our pathologists was so adamantly opposed to what many thought was the madness of lumpectomy that I had to threaten to fire that pathologist in order to gain cooperation!
localization biopsy or lumpectomy: This is done either with diagnostic intent or
therapeutic intent. Under imaging guidance, a radiologist injects some blue dye in and around
the abnormality so that a surgeon can surgically remove all or a portion of the dye-marked
area, as in #12 or #19 below. The removed lump may be x-rayed in order to be sure that any
calcified or shaped abnormality was, in fact, taken out. The lump is then sent to our
pathologists for processing and interpretation. Unless the surface edges of the removed lump of
tissue are obviously positive for cancer to the naked eye examination, our pathology group
always coats the surface with ink prior to fixation (firming-up and preserving) of the
specimen. Then, when it is sliced and further processed, the presence of the ink on the
microscopic slide can be related to any malignant tumor in order to know whether tumor was
actually cut across by the surgical margin or not. Our pathologists not only diagnose, grade,
and determine all sorts of other parameters of any malignancy; but, we are able to measure and
comment upon the adequacy of the margin of uninvolved tissue surrounding any malignancy as it
was removed. This specimen could turn out to be a type of lumpectomy or partial mastectomy. Our
radiation oncologist uses ultrasound to relocate the internal lumpectomy site if the lump is
cancerous and radiation is added postoperatively for conservative breast treatment. Our
hospital has this.
- metallic-wire (needle) localization diagnostic biopsy or lumpectomy
or therapeutic lumpectomy: This is done either with diagnostic intent or therapeutic
intent. Under imaging guidance, the radiologist inserts one or more wire marker needles (rather
than dye) around the abnormality (needle localized lumpectomy" if only one needle; "needle
bracketed lumpectomy" if more than one needle). Our hospital has
- Intra-operative ultrasound-guided lumpectomy: The surgeon
uses the instrument in the OR. We have this.
- Ultrasound-guided, large-core needle biopsy (LCNB): using
images prepared from sound waves (as in sonar detection of submarines), the radiologist sticks
a biopsy needle through the breast skin into the ultrasound-localized area of abnormality,
usually being a lump which can be felt, usually biopsying out one or more
skinny cores of tissue for diagnosis by our pathologists. A quick procedure, and metallic
lesion markers usually not placed. Answer available next day. Our hospital has
- Stereotactic-guided large-core needle biopsy (LCNB): mammographic
digital images are utilized in order for a qualified radiologist or surgeon to very carefully
and precisely biopsy the abnormality (usually a target lesion which can't be
felt and may be poorly delineated on imaging studies) while the patient is immobilized
and the breast is kept in a precise position...sometimes for a prolonged period of time. A
small skin incision is used, and the skinny biopsy cores are processed and interpreted by our
pathologists. Abnormalities which are especially deep or far toward the underarm my not be
sampled this way. Importantly, the pathologist and radiologist collaborate to be sure the
biopsy pieces actually contained part of the target lesion. Metallic lesion markers usually not
placed. Answer available next day. Although I'm not aware of any missed cancers in our LCNB
procedures, the false
negative rate is published as 2% (JAMA 5 May 1999, p. 1638-1641). Our
hospital has this.
vacuum assisted Mammotome very-large-core biopsy and/or resection of abnormal area:
qualified radiologist or surgeon inserts a small, cylindrical, hollow, image-guided instrument
into the area of the abnormality (usually a target lesion which can't be felt)
, and the abnormality (target lesion) is sucked into the biopsy groove & sequentially
snipped off into the cylinder and removed. The tissue core portions are processed and
interpreted by our pathologists. A tiny metallic marker is inserted where the target lesion was
so that a radiation oncologist will have an exact tumor site to focus radiation on if the
target turns out to be cancer. Our radiologists perform this much more frequently than
stereotactic biopsy. Answer available next day. Our hospital has this. There is also an
ABBI System instrument and a SenoCor 360™ instrument for large-core
sampling...we do not do this.
- Ultrasound-guided, mobile, hand-held mammotome large-core needle
biopsy (LCNB): using images prepared from sound waves (as in sonar detection of
submarines), the radiologist sticks the penetrating end of a hand-held wand through the breast
skin into the ultrasound-localized area of abnormality, usually being a lump which can
be felt (but can be an actual mass which can just be seen, biopsying out cores of
tissue for diagnosis by our pathologists, as above. A procedure that doesn't require prolonged
patient and breast immobilization in an imaging device: and, multiple specimens taken during
only one instrument insertion...including metallic marker placement. Answer available next day.
Our hospital has this.
core biopsy: we added this in 2008.
needle-core biopsy: similar to some of the above, often as a doctor's office
procedure, a needle biopsy instrument is inserted through the skin into an abnormality which
the doctor can actually feel, and a core of tissue is removed for processing and interpretation
by a qualified pathologist. Metallic lesion markers not placed. Answer available next day....if
the office sends the specimen to our pathologists (some health coverages require that
doctor's-office specimens be sent elsewhere). Our hospital has
biopsy: usually under operating-room conditions, the skin is opened and a
PART of the abnormal area which your surgeon can actually feel is removed
(like a slice from an apple) for processing and interpretation by our pathologists. Our
hospital has this.
biopsy: the goal is that the ENTIRE abnormal area which can be felt
by your surgeon is removed and sent for processing and interpretation by our pathologists.
Excisional biopsy (diagnostic lumpectomy) is referred to as a therapeutic
lumpectomy if the surgeon's intent is to remove the abnormal area plus some surrounding
uninvolved rim (or margin) of breast tissue. It is an excisional biopsy when the goal was
"entire sampling" rather than tumor removal plus some surrounding normal breast tissue. Our
hospital has this.
maximally oriented: as in the above lumpectomies, but the sample is kept perfectly
oriented as to how each aspect of it relates to up (superior) or down (inferior), front
(anterior) or back (chest wall, dorsal, or posterior), right or left, medial (toward breast
bone) or lateral (toward the side) in your breast. If the lesion turns out to be cancer, and if
any cancer is found remaining on the edge of the removed specimen, we can know more exactly
where. Then, your doctors are able to very precisely plan any additional surgery (completion
lumpectomy) and/or focused-and-exactly-targeted x-ray therapy. This approach leaves the patient
and her doctors in a position to consider any one of a complete array of conservative options,
the accuracy of everything depending on specimen processing and interpretation by our
interested and qualified pathologist. Our hospital has this.
lumpectomy: This procedure may follow a lumpectomy or excisional biopsy removal of a
cancer if the pathology study on the specimen for the first surgery indicates that some tumor
was left behind. It surgically removes all or part of the recent, partly healed lumpectomy
site; it is less than a mastectomy but could result in a partial mastectomy. Our hospital has
mastectomy: This procedure classically removes a fifth (20%) or more of a breast in an
attempt to remove a tumor and conserve much of the breast. Depending on the size of the removed
piece of tissue, lumpectomies are often called "partial mastectomies" (especially if the cancer
diagnosis is already a proven diagnosis. Additional terms in this category are: wide local
excision, segmental excision, quadrantectomy (25% of the breast), and tylectomy (from a Greek
word meaning "removal of a knot"). Our hospital has this.
mastectomy: when one goes back and finishes an incomplete mastectomy of any type. Our
hospital has this.
mastectomy: This procedure entirely removes the breast but without an attempt to also
remove the embryonic "milk line" between breast and axilla and without removing the lymph
nodes. Our hospital has this.
radical mastectomy (MRM): This procedure removes the breast plus some or all of the
lymph nodes under the arm on the same side. Our hospital has
- Skin sparing
modified radical mastectomy (SSM): This mastectomy for when skin is not near the cancer and
breast reconstruction is planned. Our hospital has this.
sparing Mastectomy (NSM): This mastectomy for when skin is not near the cancer and
breast reconstruction is planned. To maximize the chances of
recurrent or new cancer in this location, the surgeon must
be quite experienced & compulsive at removing all of the
breast-tissue axillary tail. Our hospital has this.
- Bilateral skin sparing mastectomy with immediate or delayed plastic reconstruction: Whether to immediately reconstruct or delay depends on many factors.
mammoplasty: This procedure removes large quantities of tissue from breasts which are
determined to be overly enlarged. In most laboratories, a representative, unselected, several
pieces of breast tissue are processed for microscopic examination. We have developed a
procedure which markedly refines the initial examination of these large quantities of breast
tissue in order to greatly increase the likelihood that we will actually find, process, and
interpret any occult premalignant or malignant areas in the one or two large buckets full of
mammoplasty tissues. Our hospital has this.
- Mastopexy: Breast skin and some breast tissue are removed in
an attempt to reduce "sag". Our hospital has this.
- Sentinel node (SLN) biopsy: In this procedure a radioactive
tracer (and possibly also some blue dye) is injected around a known area of invasive or
non-invasive cancer or around the areola. The tracer is carefully followed to the first lymph
node draining that part of the breast. Rarely, it can detect that drainage goes toward more
than one direction. Thus, the surgeon is enabled to detect the correct drainage pattern and to
select the lymph node closest to the cancer (even if it is a small node which can not be felt
at surgery...and we have often found even small nodes to contain cancer) and remove it.
Depending on the pathology findings in the breast lump AND that closest lymph node (a lower
grade cancer and a "negative sentinel node), it may become possible to avoid lymph node
dissection of the axillary tissue up under the arm...thereby avoiding the morbidity from
axillary lymph node dissection (ALND). In cases of breast cancer greater than 5 cm. (2 inches)
diameter, pre-operative chemotherapy (neo-adjuvant chemo) may be followed by chest wall and
axillary radiation therapy WITHOUT axillary dissection if the sentinel node is negative.
Elsewhere, programs have found that less than 2% of cases have a negative sentinel node but a
positive one in the axilla (a 2% risk of miss-prediction of ALND node status based on SLN node
status)....a best performance possible being a rate of only 0.0017%. We started this at
Lexington Medical Center in early 1998. We have always processed entire nodes (unless some are
obviously positive) in all types of cancer cases since about 1980. We began selective intense
processing in October 2000 and across-the-board intense processing 11/11/02...one of the first
labs in the USA to do so.
If the surgeon discovers a distinctly abnormal appearing
SLN...highly suspicious for being a "positive" metastatic node, it is reasonable for the
surgeon to request a frozen section confirmation so that they can proceed immediately to
axillary node dissection (ALND) and avoid a second axillary procedure, later. In order to avoid
waste of a node submitted as such, a pathologist may elect to attempt the intraoperative
diagnosis using a STAT cytology touch prep.
If final pathological exam shows that the SLN contains
metastatic tumor, the pattern of metastasis is somewhat predictive of additional positivity of
the additional non-SLNs: extracapsular extension of tumor is 80% predictive that one or more
non-SLNs will be positive, whereas lesser positivity of the SLN is only as high 32% predictive.
Memorial Sloan Kettering Cancer Center has (as of 2/2004) a new on-line prediction tool
[here]. You or your pathologist inputs online
information about your cancer pathology and the detection methods used to analyze your
nodes. The program then calculates then % chance that other axillary nodes remaining in you
already contain cancer. If the risk is high enough, additional surgery and/or axillary and
collar-bone area radiation therapy are advisable. Our hospital has all of
- Axillary lymph node dissection (ALND): Decades ago, prior to
conservative breast surgery (CBS), all lymph nodes under the arm pit were removed during
radical mastectomy (levels 1-3). Now, unless a special situation demands it, the nodes closest
to the breast (level 1...maybe some 2) are removed in order to decrease the odds of the
complication of lymphedema of that arm. It is crucial in ALND, SLN biopsy, and extended ALND
that a really thorough (uncommon in most labs as of beginning 2003) exam be performed
(we at Lexington do an intensively thorough exam on most cases...not
surpassed in thoroughness by any other lab in the world). Our hospital has
ALND: if the typical ALND or the SLN biopsy remove only a few nodes and most or all
are positive for cancer, another surgery will/may be performed in an attempt to remove what are
likely to be some more positive lymph nodes that are still higher in the patient's
armpit/axilla. Using the same intensive search method, our hospital has
reconstruction (immediate and/or delayed): Even though (especially from plastic
surgeons view-point) there are reports that reconstruction at the time of cancer surgery
(immediate reconstruction) works as well as delayed, I am highly skeptical of such general
advice. I fear women diverting their immediate priority concern to future cosmetic effect
rather than to a maximal effort toward conserving their life; it is my understanding that the
program at the renowned M. D. Anderson Center in Houston will not perform immediate
reconstruction because that interferes with the probably-critical timing factors for chemo and
radiation therapy! Our hospital has this.
- Radiation Oncology (therapy): expert services provided by doctor
John Ravita. Please keep in mind that radiation therapy is not advisable or helpful to the
breast in all cases. If breasts are too large or too pendulous/ptotic (sagging), radiation
may be out. The expert RADIATION doctor is in the best position to advise pro or con. So, don't
automatically be planning your treatment in your mind without being aware that some treatments
may not be an option for you. Current external radiation treatments (XRT) are taken over about
7 weeks. We have IMRT, a dynamic 3D modeling and delivery of external radiation which increases
the likelihood that the breast does not suffer the effects of radiation "hot spots"...cure rate
is the same and cosmetic result even better than currently. We have the capability and
experience to do chest wall recurrence radiation seed implants; and we can use (as of May 2002)
HDR brachytherapy via temporarily inserted tubes as an alternative way to provide a quick
(entire course in 5 days) radiation plan. Another HDR technique (MammoSite) in which a balloon is inserted in an
excisional biopsy or lumpectomy cavity and subsequently filled with radiation liquid and
later removed is available (we started in September 2003). The HDR techniques require much
less time in visits to the radiation department; but the patient's breast size & shape
and tumor location features for successful use of this method are very exacting.
[for more detail
on the radiation techniques]. Our hospital has
Oncology: expert LMC services are available on our campus through doctors Steve Madden,
Asheesh Lal, and Vijaya Korrapati, etc.
If it were me, upon being
told I had breast cancer, I would involve a diagnostic radiologist, surgeon, radiation oncologist,
medical oncologist, and pathologist in decisions about further diagnostic and treatment options and
decisions. Pick one to be the "leader" for this "multidisciplinary involvement". Hopefully you'll
have access to a regularly-held, multidisciplinary conference for cases discussions (our hospital
has this). Let that person know that you expect that no decisions be made unless all are in
agreement. If there is disagreement, you are to be clearly informed. As your case progresses, you
may want to change which one is the leader.
LMC's Free Multidisciplinary Breast
As of 27 August 1999, breast cancer situations
are presented (from abnormal mammogram to late treatment discussions and decisions) at our
hospital's weekly meeting of surgeons, diagnostic radiologists, pathologists, radiation
oncologists, and medical oncologists. Key case points can be made available to each patient's
doctor, and the meeting information/decisions will be maintained in each patient's file kept by our
Breast Health Services Coordinator. This insures multidisciplinary collaboration in which the
experts are together and hear what each other has to say [rather than just reading consult reports
or having independent, isolated conversations]. For any breast patient anywhere, you certainly have
a right to a copy of any of your diagnostic radiology or pathology reports (especially since the
federal HIPAA law, you will need to be able to assure those departments of your identity prior to
being given report copies).
The optimal situation for the patient is that
any of the above diagnostic maneuvers are done through the coordinated involvement
of treating physicians, diagnostic radiologists, and diagnostic pathologists who are particularly
interested in optimizing the technical and decision-making process and treatment of breast lumps,
benign or malignant. It is usually critical that all of this process take place at the
point of care and that the specimens not be initially sent off to distant
laboratories which have no local licensing, medical staff credentialing, or other certification
and sense of "local community". An exception is to go to such a coordinated
program for work up and treatment if no such program is available in your community. The
between these local (or distant program) health care professionals is
critical to expeditious, exacting, efficient, and top quality programs.
and treatment array at Lexington Medical Center constitutes just such an optimal situation.
ADDITIONALLY: one of the major comprehensive breast programs in the USA indicates (2003) that the
presence of a sentinel node process (see above) in an institution is an independent indicator of
multidisciplinary cooperation at a very high level (many hospitals talk the talk...this is evidence
that they walk the walk, also).
PATHOLOGY INFO. TO BE DETERMINED ASAP:
When you are referred (by yourself or your doctor) to the Lexington
Medical Center Breast Health Services Program, there are four things our doctors want to know
(1) Is it benign or
This question can't always be answered on the
first, least-invasive attempt. If a final determination is "not cancer", you still need to
continue breast self exams and periodic mammograms on into the future for the rest of your
life. If it is cancer, then there are two more initial questions:
(2) What "grade" of cancer is
As with birds, dogs, and people, there are a
number of different types and personalities of cancer. Certain types of cancer are "low-grade".
Other types are rated by a grading system from low (grade I) grade to medium (grade II) to high
(grade III) grade, grade referring to the degree of "look" of badness and
aggressiveness...low-grade is "less bad" than average. Think of dogs: a small "lap
dog"...grade I; a medium sized spaniel...grade II; and a pit bull, German shepherd, or Doberman
(even a wolf)...grade III.
The pathology group at Lexington Medical Center uses the Elston modification of the
Scarf, Bloom and Richardson grading system (also known as the "Nottingham combined histological
grade") to calculate grade for invasive ductal carcinoma (IDC). The
Bloom-Richardson nuclear grading
system is used by our group for non-invasive ductal carcinoma in-situ
(DCIS or d-CIS); but our report also contains the information needed for either
the "Lagios grading
system" or the "Van Nuys Grouping system"
for grading. If you should find that some item of information is missing from the pathology report,
please contact Kelly Jeffcoat @ 803-792-2521.
(3) What "stage" is the cancer
"Stage" is a way to systematically state what
the invasive tumor size and spread is (how far the cancer has "gone") at the time of
diagnosis. The pathology group at Lexington Medical Center reports data which can be applied to any
staging system (the most widely used is the ***AJCC/TNM***
...5th & 6th editions). [Note: some pathology reports
contain T & N numbers that are part of the SNOP or SNOMED case retrieval coding systems
and have nothing to do with staging] An additional evaluation is possible for cases which are
believed to be non-invasive ductal carcinoma in-situ (DCIS)...the VNPI. You will have a
number of blood tests done (one may be for a CA27.29 "cancer marker"); and various types of imaging scans/X-rays may be done to find further evidence
helpful in concluding what "stage" your case is in, one of the most important of which is
lymph node status: are the nodes positive or negative for cancer...and, if
positive, how much & how bad is the positivity. Using the dog comparison, stage I is that grade
I, II, or III dog confined in the dog house; stage II, the dog is out in the dog pen; stage III,
the dog has dug out of its pen and is in the yard; and stage IV, out of the yard, on the attack,
and ranging around the neighborhood. If you should find that some item of information is missing
from our pathology report, please contact Kelly Jeffcoat @
(4) What are the tumor markers?
Early decisions about "the next step" after cancer diagnosis take into
consideration the estrogen and progesterone receptors status (ER & PR...both by IHC),
HER-2 oncogene product over-expression (by IHC) or gene amplification (by FISH), and evidence
of cancer proliferation rate (in addition to mitoses) by such as Ki67 (by IHC) or S-phase
status (by flow cytometry). IHC stands for immunohistochemistry stains applied to slides made
of the tumor and viewed under a standard microscope. ER- &/or PR-positive cancers need
those female hormones as if those hormones were cancer fertilizer.
LYMPH NODE STATUS:
Considerable thought is put into the decision [the MSKCC decision tool] [an example of an unpublished...KATS...decision protocol] about whether to sample axillary nodes (under the arm on the side of the
breast cancer); and, if so, whether to sample just a single first-in-line node (SLN) or more
(more as below). If your axillary lymph (invasive cancer cases) nodes were more extensively
sampled & partially removed (modern-day practice aims to remove only the level I and,
maybe, the level II nodes...more rarely, level III nodes high up in the arm-pit will be
removed), what is a "rule of thumb" for adequate sampling? Currently, 10 nodes are a good
sample and 6-8 are a very adequate sample. Lesser numbers may just be all that were
available. The older the patient...above, say, age 60...the fewer the nodes recovered
(usually). See ALND, above, about the need for thorough node evaluation.
GENETIC RISK and GENETIC
Breast and/or ovarian cancers popping up in
families or occurring at young ages (say, below age 40) tend to suggest a genetic/hereditary
predisposition. A blood test can be done; and, if it is positive for BRCA1 in a patient, there may
be an 82% chance of breast cancer by age 70 (the "normal" risk is 13%). But, a positive test does
not guarantee cancer will attack; and a negative test does not guarantee safety from breast cancer
(as only about 10% of cases have hereditary aspects). Ovarian cancer "normal" risk is about 1%; a
positive BRCA1 or BRCA2 test increases the risk to 44% (with the same lack of positive or negative
guarantees as for breast cancer).
OKAY, HOW BAD IS
Using all of the information
available, your doctors estimate how bad the situation is. They must also consider your
overall health and whether you have "comorbidities"; there are even electronic calculators to
factor in a "comorbidity score" to help consider the risk:benefit ratio or factor for you as
to the effect of any treatment options. One such score is the CCI (Charlson comorbidity
index)...on-line calculator is here [calculate your CCI]. This general health estimate of
"how strong is his/her health foundation aside from the breast cancer?" influences whether
conservative (CBS) or radical surgery is needed, whether radiation therapy is needed, and
whether pre-operative and/or postoperative chemotherapy (and what chemotherapy drug regimen to
choose) and/or hormonal manipulation is needed. The NPI is one formulaic way to initially stratify cases toward these decisions; but our
doctors seldom use it. Our pathology group has a web site, and the breast cancer listing notes some
other items (such as using MAI and MPI to help decide about adjuvant [preventive] chemotherapy
or not), including links to "nomograms" for calculating your
Correctly practiced medicine is not a thing of pure science. The
NCCN (a cooperative of 19 of the world's finest
cancer centers) website keeps decision trees ("practice guidelines") posted as recommendations
of what most experts would statistically recommend for the average (or most typical)
situations. BUT, each individual patient's situation is unique;
so, your doctor may deviate from these decision trees in his/her recommendations for reasons
that they can explain. If you are checking your case against the NCCN decision trees, you
certainly have a right to know the reasons for any suggested
"Quickie" ESTIMATING YOUR LIFETIME CHANCE
OF THE CANCER COMING BACK:
For invasive cancer, a recent, very general and
not exact, rule of thumb to use in weighing additional treatment improvement of your odds beyond
lumpectomy and lymph node dissection (beyond surgery only), based on the "average aggressive
invasive breast cancer", is: your lifetime risk of the cancer coming back is 12% for each
centimeter of the "greatest diameter of the tumor" plus 6% for each positive lymph node. Example:
your tumor is 2.0 x 1.8 x 1.5 cm. and 16 lymph nodes were removed and three were positive. Then, if
you do nothing else for treatment, your lifetime risk of tumor recurrence is 2 x 12% plus 3 x
(1) Many people have found the books and
web site info by my friend and consultant to our
breast program (and developer of many Ivy League area programs in the northeast), Judy Kneece
(started here in West Columbia & now in Charleston, S. C. HERE), to be very helpful.
(2) Some 11,000 women under 40 years of age
would be diagnosed in 2003. From 2005-2008 in our program, 31 were age 35 or younger & 726 were
36 or older. Check out the Young Survival Coalition web site in New York.
All of the above procedures are available at
Lexington Medical Center, West Columbia, S.C. For your evaluation, call the
above one-phone-call-does-it-all phone number; or, contact as
Imaging Center of Lexington Medical Center: mammograms and ultrasound breast studies.
Studies available at the hospital center, the center in Irmo, and by mobile unit. To schedule:
- Lexington Radiology
Associates, P.A. (@ Lex. Med. Ctr., W. Columbia,
- For primary
appointments to evaluate breast abnormalities by mammographic imaging, ultrasound imaging, or
ultrasound or stereotactic breast biopsy: 803-791-2486.
- Second opinions on
imaging studies performed elsewhere: 803-791-2486.
- For possible
referral information: 803-791-2486
- To arrange for us to
perform FNA of lumps you can feel: 803-791-2159.
pathologist evaluators, processors, and interpreters of...as pathologists...all of the above
types of tissue specimens: 803-791-2410.
- For possible
referral information: 803-791-2410.
Surgical Associates: 803-359-4133, in Lexington, S. C. (Drs. Charles Harmon,
Richard Felton, Paul Smith, Myron Barwick, and Lynn Tucker, etc.) & at Lex. Med. Ctr., West
Columbia, S. C.
- Southern Surgical Group:
803-796-8901, West Columbia, S. C. (Drs. Jeff Libbey, Bill Moore,
Ron Myatich, & Terry Norton, etc.) on campus of Lex. Med.
- Riverside Surgical
Columbia, S. C. (Drs. Jim Givens, Chip Strickland, Marc Antonetti, & Gray Hughes, etc.) on
campus of Lex. Med. Ctr.
me your comments about this
(posted March 1998;
latest addition 12 September