My Breast Cancer Journal
April 2-8
Sunday, April 2, 2000
We went to the surgeon Friday and got a copy of the pathology report. First, sometime this week I can start using my arm more. The armpit is much less sore, but sitting in a chair without an armrest at church today was very tiring. I had my pillow, but it just got sore and my shoulder got tight. Next time I may sit in the back by the tables so I can put my arm up.Before I start on the report, I visited Oncolink's article on Surgical Pathology and Breast Cancers. OK, the report. There are 3 major parts - macroscopic (what you can see with the naked eye), microscopic, and diagnosis.
MACROSCOPIC
The report first specifies the size of the specimen (9x8x3 cm or about 3.5 x 3.4 x 1.2 inches) and the weight (75 gm, or about 2.6 ounces). It is described as a well-circumscribed tumor, meaning that it had distinct boundaries. This is what the surgeon was talking about when he said that my body was fighting off the cancer. It had built a wall around it and was trying to contain it. The report then gives the greatest dimension of the tumor (the longest or widest measurement): 1.8 cm. That's great! Anything under 2 cm is still considered small and classed as stage 1 cancer. The report now says that the pathologist made multiple sections through the tumor and labeled them for further study. It then finished the macroscopic examination by noting that the tumor was firm and fleshy. I'm not exactly sure whether this is significant, so I'm marking it for further research.The macroscopic report also describes the lymph nodes that the surgeon took out. First, the size of the tissue removed was 10 x 5 x 2 cm (or about 4 x 2 x 1.8 inches). Weight: 23 grams (or 0.8 ounces). It also includes the range of size of the nodes taken out and notes that each node was labeled for further study. The report also notes that some of the nodes were indurated, or hardened.
Aside: I want to say that the discomfort from the axillary dissection is far and away worse than the breast incision. This is because the surgeon had to cut a major branch of a cutaneous nerve. I've read that some women have lifelong changes in sensation from an axillary dissection - numbness, tingling, pain - but my surgeon says he tries to be very careful to do as little damage as possible when doing the axillary dissection. I had one day where my arm was completely numb, and every day it's gotten better and better. I think that I am going to have very few residual effects from this dissection if I can wait out the healing period.
MICROSCOPIC
This part is much harder to read and the words are scarier looking. I'm going to try to wade through this with my medical dictionary. First, it says that the tumor consisted of a very large eosinophilic anaplastic malignant cells. OK, first off, I know that eosinophils are part of the immune system. If you have asthma or allergies, eosinophils have a big part in your disease. But this isn't saying the cells are eosinophils. It says they are eosinophilic, which simply means that they responded to the eosin stain (or dye) the way an eosinophil would. I can't find anything on the significance of this, so I'll mark it for more study. Anaplastic means undifferentiated. These are cells that are so confused, they don't know what they are supposed to develop into. I'm sorry to say that it is better if the cells are noted to be "well differentiated" so this is not the best news. Finally, the note that these are malignant cells. In other words, these cells aren't just confused, they are cancer. They are confused and therefore acting in ways that are threatening to me. Boy! Glad we took those beasties out!Next it says that the tumor was formed into nodules by additional fibrous connective tissue proliferations. This is abnormal, but benign and from what I can find, it's not associated with any increased risk of recurrence. Nevertheless, I'm going to continue to look for more information on this.
Now we get to the part I was most curious about - the tumor grade. The pathologist notes that he used a modified Blume and Richardson method to grade the tumor. I haven't been able to find any documentation on this, but here is something from Oncolink on tissue grading. I can't find anything else on this right now, so again, I'm going to go through this quickly but mark it for more research. First, he gives me tumor a score of 3 on tubule formation because the sheets of cells contain no lumina. A tubule is just a small tube, the lumen is the opening that goes through the tube. So basically, he's saying there weren't any tubules in my tumor. This is consistent with the observation that my beasties weren't differentiated - they simply weren't organized enough to start forming tubules. Again, a lower score would have been better, but my beasties just get a 3. They also got a 3 on the nuclear pleomorphism score. Nuclear pleomorphism describes the variety of forms seen in the nuclei of the cells in the tumor. Again, I need to do more research on this, but I believe that one "good" breast cell is going to pretty much look like another, so pleomorphism (where things all look different and confused) is bad. Again, a lower score would have been better. A person could start to get bummed out, except the good news is coming up next. My tumor got a score of 1 on mitotic rate. That means it's a very slow-growing cancer, and we like that!
The microscopic section goes on to note that fibrocystic changes are noted on some of the slide. This is not significant. It then notes that "dilated and cystic glands had undergone apocrine metaplasia." This is also a nonproliferative benign change that does is not positively correlated with an increased risk of cancer. According to Oncolink, "Sixty-nine percent of the reviewed biopsies were found to have nonproliferative breast disease" so it's not unexpected to have these kinds of notations on this report. More about nonproliferative breast changes and their relationship to risk of developing cancer can be found at Oncolink's Risk Factors and Breast Cancer page.
The microscopic section of the report finishes with a list of things that were NOT found on this biopsy:
ductal carcinoma in situ (an earlier stage of the type of cancer I have)
hyperplasia (an abnormal increase in normal cells in a normal arrangement)
atypical hyperplasia (a benign condition that carries a significantly increased risk for developing breast cancer)
This is calling "ruling out" - it means the pathologist considered these other conditions when developing his diagnostic opinion and he ruled them out.Next, the lymph nodes are considered. They are noted to be well-encapsulated. They have extensive areas of fatty infiltration and replacement of the lymph nodes. Here's a really gruesome picture of some lymph nodes. I didn't turn up anything about what this means on a quick scan of Oncolink, but I think it is benign. Possibly means I need to lose weight (which is definitely true). Finally, the report says that the lymphoid elements appeared regular. Hooray! This is the good news that the nodes are normal. No beasties. Terrific news!
posted by Karen Weber Sunday, April 2, 2000
Well, blogger cut off the final portion of what I wrote about the diagnosis section of the report, but I'm too tired right now to do it again. I'll work on it tomorrow.
posted by Karen Weber Sunday, April 2, 2000
Tuesday, April 4, 2000
OK, I'm going to finally finish up the diagnosis section of the path report.DIAGNOSIS
1 Infiltrating ductal carcinoma of the breast (from Oncolink: the most common cell type, comprising 70% to 80% of all cases. The tumors occur throughout the age range of breast carcinoma, being most common in women in their middle to late 50s. It is characterized by its solid core, which is usually hard and firm on palpation. An associated ductal carcinoma in-situ is frequently present and comedo necrosis may occur in both invasive areas and areas of intraductal carcinoma. Invasive ductal carcinoma commonly spreads to the regional lymph nodes and carries the poorest prognosis among various ductal types. Nuclear and histologic grade have shown to be effective predictors of prognosis.)Medullary type (from Oncolink: characterized by a prominent lymphocyte infiltrate. Patients with medullary carcinoma tend to be younger than those with other types of breast cancer. The prognosis is also believed to be better than for invasive ductal cancer. ) So you can see why my surgeon was excited to get the subtype results back. It paints a more optimistic picture.
1.8 cm (again, under that cut off point at 2 cm - yipppee!)
Margins free of tumor (that's good)
2. No cancer in the lymph nodes.
That's all for this path report. More work is still being done on whether the tumor is responsive to hormones. I saw this article in today's paper on protein markers being used in Europe to rule out need for chemotherapy. This is something I'm definitely going to ask the medical oncologist about. Speaking of which, the nurse at the surgeon's office called yesterday. I'll be seeing the medical oncologist on either April 20 or April 25 and his name is Irwin Tischler. (More press releases about cancer at the American Association for Cancer Research by the way, including one about a compound that seems to stop chemotherapy-induced hair loss in mice. Speaking of which, I have an appointment for a hair cut today. Some of you know that I used to keep my hair trimmed extremely short. When I blew out my knee, I grew it long. It's currently just below shoulder length, but I'm having so many problems regulating my body temperature that I think I'm going short again. Rick is in agreement with me on this. (And I know my mother will be jumping up and down for joy, so if you hear reports of an earthquake later today centered in the Prescott area, she's heard the news.)
posted by Karen Weber Tuesday, April 4, 2000
I spent several hours reading at PubMed today. Printed out a number of articles for further study. Basically, it appears that if the cancer really is the medullary type there is no benefit to having either chemotherapy or radiation. 97% survival rate with just surgery. Same rate with surgery and radiation therapy. Same rate with surgery, radiation therapy, and chemotherapy. (This is the rate for node negative medullary cancer only, so I'm glad those nodes were negative!) The kicker is that it's fairly difficult to be sure of this diagnosis apparently. So, Rick and I are in agreement that we are not going to do chemotherapy just to do it. I want some folks at a major cancer center to look at my slides to see if they agree with the diagnosis. If they do, I cannot see putting myself through chemotherapy "just in case." Especially with the recent research on the measurable loss of intelligence following chemotherapy. I don't have enough brain cells that I want to just wantonly sacrifice them "just in case." So it may take some time to make a decision on the next thing we do. I will definitely pursue a second opinion before making any decision.In reading at PubMed, it does look good that my beastie is medullary. The fact that the cells were eosinophilic points to the lymphocyte infiltrate that is characteristic of this type of cancer. Also, there were no tubules. In typical medullary cancer (and that's the kind with the good prognosis) there is "no tubular component." Also encouraging, size and grade of the tumor doesn't really have any impact on the survival rate for medullary cancer. As long as it was a well circumscribed tumor with the lymphocyte infiltrate and no tubular component, those things aren't factors. Neither is my age. The medical literature calls this paradoxical. I call it GREAT! I printed those articles out and I'll read them more carefully, but I sure am encouraged right now.
Got a call from my mother reporting an earthquake in Prescott. She measured it at 7 on the Richter scale. No damage reports received.
posted by Karen Weber Tuesday, April 4, 2000
Thursday, April 6, 2000
I have a post-op surgical visit today. I have been watching a small area on the incision on the breast for several days now. It is red and has been weepy. Yesterday the exudate (the weeping fluid) was blood-tinged. I'm not really concerned about this, however, as the spot isn't getting any bigger or redder. I think this is an undisolvable knot working its way out. I had this same thing happen with my last knee surgery. I just waited until I saw the tip of a thread and pulled it out, then it healed right up. (Of course, I had cleared this with the surgeon first. I don't recommend randomly pulling threads out of your body - you may come all undone!) Anyway, I'm sure that's what this is.This morning, however, I have a new concern. Yesterday, the axillary incision looked great. Today, about an inch of it is bright red and the skin in a 2x3 area around it is also inflamed. Warmer to the touch than the surrounding tissue. All signs of infection. I am concerned about this. If I didn't already have an appointment with the surgeon today, I'd be making one for sure.
posted by Karen Weber Thursday, April 6, 2000
I just got off the phone with the Cancer Information Center. They were unable to tell me where research is being done on medullary carcinoma of the breast, but did refer me to a good source for second opinions on rare lesions: AFIP - (Armed Forces Institute of Pathology). This is a non-profit commissioned by Congress and working in conjunction with the American Registry of Pathology to provide these services to civilians as well as people in the services. I'll be taking this information in to the surgeon this afternoon in the hopes that we can have this second opinion done before I meet with the medical oncologist.
posted by Karen Weber Thursday, April 6, 2000
Well, I had a good visit to the surgeon. Both red areas are stitches trying to work themselves out. The one in the armpit was so impressive that he decided he was going to dig that stitch out. So he did. Not really very pleasant, but the swelling and redness are already going down so it was worth it. He also gave me a prescription of antibiotics for skin infections and assured me that it was going to clear up quickly. No trouble with the trip to Hawaii. I made a couple stops on the way home, then collapsed when I got here. I laid down for a short nap. Nichol, who works for me, came over while I was sleeping. She always rings the doorbell, then lets herself in. Well, the doorbell rings in the bed room and I didn't even hear it. Dead to the world. Not much good for anything tonight, but I paid some bills so that won't be hanging over my head while we are gone.
posted by Karen Weber Thursday, April 6, 2000