There's An Abnormality In My Breast!

The Truth... What is it?

Breast Diagnosis

THERE'S AN ABNORMALITY IN MY BREAST

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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.

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TAKE CHARGE
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. AND, believe it or not, many a women has said that getting breast cancer turned out to be a positive thing in their lives (Gerri Willis interview, HERE & HERE), even the best thing that ever happened to them...examples HERE and HERE.

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.

OUR PROGRAM
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 costs.

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).

IMPATIENCE WARNING!!!!!!!!!!!!!!!!!!!

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 resource?***

TYPES OF TESTS & TUMOR SAMPLING PROCEDURES AT LEXINGTON MEDICAL CENTER:

Screening 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.
Screening mammography, digital: we added this improvement in late 2007.
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.
Ultrasound (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.
Ultrasound, 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 about 12/1/06.
Magnetic 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.
Magnetic 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 has this.
Homologous 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 this.
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.
Cyst 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).
Duct 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 program.
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!
Dye 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 this.
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 this.
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.
Stereotactic 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.
MRI-guided core biopsy: we added this in 2008.
True-cut 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 this.
Incisional 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.
Excisional 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.
Lumpectomy, 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.
Completion 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 this.
Partial 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.
Completion mastectomy: when one goes back and finishes an incomplete mastectomy of any type. Our hospital has this.
Simple 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.
Modified 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 this.
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.
Nipple 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.
Reduction 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 these.
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 this.
extended 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 this.
Breast 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 this.
Medical Oncology: expert LMC services are available on our campus through doctors Steve Madden, Asheesh Lal, and Vijaya Korrapati, etc.

CAVEAT EMPTOR:...TAKE NOTE

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 Conference

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 multi-disciplinary interplay between these local (or distant program) health care professionals is critical to expeditious, exacting, efficient, and top quality programs.

Our diagnosis 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).

INITIAL CRITICAL 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 ASAP:

(1) Is it benign or malignant?

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 it?

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 in?

"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 @ 803-792-2521.

(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 TESTING:

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 IT?

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 chances.

TREATMENT DECISION TREES

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 deviations!

"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 6%=42%.

TWO INFORMATION RESOURCES:

(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.

GETTING A DIAGNOSIS:

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 follows:

Women's 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: 803-791-2486.
Lexington Radiology Associates, P.A. (@ Lex. Med. Ctr., W. Columbia, S. C.):

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

Pathology Associates of Lexington, P.A. (@ Lex. Med. Ctr., W. Columbia, S. C.):

To arrange for us to perform FNA of lumps you can feel: 803-791-2159.
Qualified 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.

Lexington 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. Ctr.
Riverside Surgical Group: 803-791-2828,West Columbia, S. C. (Drs. Jim Givens, Chip Strickland, Marc Antonetti, & Gray Hughes, etc.) on campus of Lex. Med. Ctr.

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(posted March 1998; latest addition 5 April 2017)

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