Everything and Its Dog

Here’s a quiz.

Which of the items listed below is something you *do not* want to see on a pathology report after a breast biopsy?

A.  Fibrocystic changes
B.  Hyperplasia
C.  Microcalcifications
D.  Columnar cell change
E.  Atypical hyperplasia
F.  Sclerosing adenosis

The answer is E.

Thankfully, item E did not show up on the pathology report from the two biopsies I had of the right breast two days ago.  This was the good news Dr. L delivered when I answered my buzzing cell phone this morning.  Every other term listed here appears on the report. I had no idea there were so many varieties of benign cell changes in the female breast. Some of them sound pretty awful, but even hyperplasia is OK as long as it’s not atypical, a situation that could indicate the beginnings of cancer.

The biopsies were the result of some “suspicious findings” (as the pathology report puts it) on the right side on the 6-month follow-up MRI scans I had taken last week.  (Skipped those dastardly mammograms, thank you, and went directly to the big machine.) Fortunately, all is clear on the left side where surgery was done a year ago. Dr. L gave me the choice of having the biopsies or waiting another 6 months and checking again.

Look, I’ve learned a lot about mastering anxiety over the past year with stones, yoga, prayer and all those “woo-woo” techniques, but I’d have to be nuts to just wait.  So there I was again a few days later, face down on the MRI table, arms overhead as in a poorly executed dive, breasts inserted into their appropriate slots, allowing Dr. B to poke me with large needles.

This biopsy differed from earlier ones in that it was stereotactic, which means the technician calculated the exact locations of the “suspicious findings” using a computer and the MRI images.  The previous biopsies were done with me on my back while the radiologist located the problem areas using ultrasound.  A stereotactic biopsy is called for when the abnormal areas are too small to be located on either mammogram or ultrasound. The computer lines up the coordinates and the doctor can extract what is needed  for analysis and place a tiny clip in the spot that was biopsied for future reference.  Dr. B took  6 samples from a spot at the 8-o’clock position on the breast, and 12 from the spot at the 10-o’clock position.

You’d think that, with all the holes poked in my breasts by now, anything nasty would just leak out. If we keep going at this rate, I’ll be down a cup size, but I don’t think bra manufacturers make anything smaller than what I’ve already got.

By itself, the MRI procedure is nothing to fear.  No sharp instruments, no radiation. Just some loud banging and knocking. Though your position may not be the most comfortable, you do at least get a headset and your choice of music to listen to.  During the initial scan, I chose classical music, and was nearly in tears when Tchaikovsky’s “Waltz of the Flowers” came to my ears.  It’s not that I particularly love Tchaikovsky or  the over-sentimentalized “Nutcracker,” but what it brought to mind in that moment were the many dance recitals of my childhood, on the stage in my costume under those hot lights. (Surely every ballet student has danced that waltz.) In my dread of what the MRI might find, the music reminded me of a childhood long since gone.  Beauty and happiness are often recognized only in hindsight.

Next, as if to remind me of the task at hand, came The 1812 Overture. It must have been the day to play Tchaikovsky’s greatest hits. The knocks and bangs of the MRI fit nicely with the cannon shots in the music.

But there was no music during the biopsy, and when I sat up at the end, it was mildly disconcerting to see a puddle of my own blood on the tray below where my breast had been.  The MRI may be able to pinpoint a tiny lesion, but it can’t tell you where the nerves and blood vessels are, and these structures can become “collateral damage” during the procedure.  The 8-o’clock spot in particular kept bleeding, so the nurses applied a large compression bandage — lots of gauze and adhesive tape — that instantly doubled my breast size.

Frankly, size can matter, but bigger is not better.

While they were applying the bandage, Dr. B came back in to speak with me, and I asked him the question I’m sure every doc hates to hear:  “What do you think it might be?”

Without test results in hand, it’s almost unfair for a patient to try to pin a physician down to a diagnosis.

Dr. B is a soft-spoken man with the delicate lilt of a North Carolina accent who raises llamas in his off hours. He has done 4 of the 5 biopsies I’ve had. If things keep on as they have, we will become good friends. As he put it, MRIs light up “everything and its dog,” and produce a fair number of false positive results, which is one of the reasons insurance companies don’t like to cover them for people like me (not to mention they’re much more expensive than mammograms).

Based on what he saw on the images, he guessed that the enhanced areas were not likely to be trouble, but we couldn’t be sure until the pathology report came back. Some of what appeared on the images had been apparent back in January and could be attributed to hormonal changes, but now that I’ve been forced into menopause by the chemotherapy, the doctors figured those changes should have disappeared.

Well, y’know, I can be a little slow sometimes.

The technician who runs the MRI told me they do about 5 stereotactic breast biopsies a day, largely for people like me with dense tissue. Numbers like these (25 a week, more than 1200 a year) for tests that produce many false positives are as disturbing as the false negatives of mammograms. Clearly, we need more accurate methods of diagnosis.

Advertisements

In the Beginning…

So here’s where we are today, June 4, 2009, the beginning of my own personal Odyssey:

The MRI yesterday showed that the lesion in my left breast is about 1 cm, smaller than I was expecting given the size of what I felt after a shower a just before Memorial Day. It “lights up” on the images, which indicates malignancy.  The docs noticed another area on the left that didn’t light up but that they wanted to check out, along with checking the right side.

So today I had another ultrasound of both sides.  The second spot on the left is smaller and they don’t think it’s a problem but want to be sure, so I have a biopsy for that tomorrow. (The ultrasounds are quite comfortable — the biopsy, well, that’s another critter altogether.)  Everything on the right side looks OK. We’ll probably have the results of that biopsy on Monday.  And I’ll talk with an oncologist early next week to get his input.

The malignant lump needs to come out, so I anticipate some sort of surgery mid to late next week.  If the second spot is benign, we can do a lumpectomy and they’ll check the sentinel lymph node.  If the other spot needs to come out too, the surgery will be more extensive.  For a lumpectomy, it’s “same day service.”  For something more extensive, it’s an overnight stay.

More to come as the drama unfolds….