MX Path Report : What Happened ?

hmr

My mother saw her BS. He says her total MX path report found nothing. No radiation necessary but he's referring her to an oncologist for tamoxifen to protect her other breast. Please don't misunderstand. We appreciate ( apparent ) good news but what happened here ? Lumpectomy and re-incision path reports specifically described poor margins with measurements necessitating further surgery. I read over her MX path report. Unlike the previous two reports, no mention of margins and measurements at all. Final diagnosis reads " Unequivocal in-situ or invasive carcinoma not identified. No other significant histopathological changes present. Skin and nipple unremarkable." No mention of DCIS at all in the body of the path report. Just alot of comments pertaining to tissue trauma from surgery, specimen size, etc. Considering the drama leading up to the total MX what happened ? Is this outcome reasonable or has something gone awry ?

THANK YOU VERY MUCH for any feedback.

idaho

Did the same doctor do  all three surgeries?   Something doesn't sound right .... Tami

Kitchenwitch

Hmr, Can only say I would press surgeon VERY STRONGLY for an explanation. I have had a lumpectomy and re-excision and have to be honest, my big fear is that I'll be told I need a mastectomy, and then the path report on that will show ... nothing.

 How is your mother taking this news?

dsj

I don't know what to say either about whether this is or isn't reasonable.  But if  it were me, I would also worry until I got it straight.  I would definitely speak to the surgeon and the oncologist.  I would also consider getting a second opinion on the pathology.  I guess, the bottom line for me, having gone through a difficult decision about adequate margins, is that I needed to get consensus from more than one doctor.  

Mantra

I had a lumpectomy. One margin was a bit smaller than it should be. Given that 8 tumours were found in two quadrants during my lumpectomy, it was recommended that I have a mastectomy. The mastectomy showed no additional cancer. So basically I had what turned out to be an unnecessary mastectomy since all cancer was infact removed during the lumpectomy. The mastectomy report showed nothing because there was nothing to show. Not sure if your mom's situation is similar to mine but thought I'd share my story just incase.

hmr

First, thanks to all for the feedback. Well, Mantra, if the pathology reports are accurate it looks like my mother is in the same boat with you. We all feel the same way about this. Definitely surprised and upset that a MX may not have been necessary ( hindsight is 20:20 ). We would have felt better overall if the MX path report had identified some DCIS activity. I have a copy of the MX path report right here in front of me. In addition to what I posted in my previous post, most of the report is devoted to a " Gross Description " full of comments pertaining to specimen size, ductal hyperplasia, cavity formation, quadrants, fibrous tissue, fat necrosis, foreign body giant cell reaction, deep margins, superficial caudal margins, etc. Unlike the lumpectomy and re-incision path reports, there are no comments about DCIS and margins with mm. measurements. FWIW, the same BS performed all 3 surgeries at the same hospital. The pathology reports were prepared by 3 different pathologists. 

Mantra

Hmr - Yes, exactly the same as my report.

dsj

Although it seems problematic (even counter-intuitive) to me, apparently it is the case that there is no standard format for the pathology report.  So the fact that it's arranged or worded differently may be a function of who is the writer.  That said, I would want to know for sure if the 3rd pathology report is right. It seems to me that there are 3 possibilities:

1.  All of your mother's DCIS actually was excised in the lumpectomy.  That is, though the margins were close (or even involved) from the lumpectomy, the surgeon did, in fact, get it all.

2.  When they do the pathology, they don't investigate every cell.  Rather, they sample.  So, it may be that there was more DCIS in her breast, but it didn't appear in the tissue they actually looked at after the mastectomy.

3.  The third (or first or second) pathology report was wrong.

If it were me, I think I would go for having the pathology from the mastectomy reviewed by another pathologist (just to put my mind at rest).  But if it turns out there is no more DCIS in her breast, then I think it is the case that there is no further treatment, except possibly tamoxifen to counter the increased risk of the second breast.

JennyB100104

Hmr, That sounds exactly how my 2nd path report read for my reexcision. My first one was ugly--positive margins all around, so I expected them to see something on the second one...but there was zero, nothing. Same wording as your mom's!

I'm guessing the reason for that (in my case, at least--note that I didn't have a complete mastectomy, only a partial) was because they only looked at the outside margins of the removed tissue, and since those were clean, there was no need to check out the inside margins (which probably still had a few cancerous cells floating around). Does that make sense? They can't test every single cell in the tissue they take out in the mastectomy.

sweatyspice

I had a conversation about this with my rad onc today (she went off on a tangent, I wasn't asking about it).  According to her, the unpleasant cells are like marbles floating in a sea of chicken fat.  When they do the pathology, it's possible for one of the marbles to slide over to the edge of the sample, making it seem as if the margins aren't what they should be, when in fact the margins are fine.   If that makes any sense.

Maybe that's what happened. 

hmr

Good point. I wonder about that.  Movement / shifting of DCIS cells within the specimen. For instance, the path report from my mother's second surgery ( re-excision ) states that the lateral margin " was positive for carcinoma ". I take that to mean that DCIS cells were found right up to the margin edge ? Wouldn't you think that her next path report ( MX ) would show some spillover DCIS cell activity if that were the case ? 

MarieKelly

A few years back, there was another thread asking these same types of questions about how a re-excision and/or mastectomy done for dirty margins can result in no remaining cancer being found. It peaked my interest back then and I went looking for and found an explaination.  

The problem (or at least part of it) is apparently due to the way specimens are processed after they've been surgically removed.  It's called "the Pancake Phenomenon" and you all can plug that quoted phrase into a search engine along with additional words like specimen and compression to find more information about it.  Scary thing about all this is that it does seem to imply there are many women out there who've been needlessly subjected to repeat excision and mastectomy.

Here's what I had bookmarked from a previous search -

http://www.daax.co.uk/downloads/BCT_Technical_Presentation.pdf

On page 19 of this presentation linked to above, you'll see a comparision of breast cancer specimen showing how margins can be falsely negative (or falsely insufficient) depending on the way it's viewed after having been compressed.

On page 22 of this same presentation, is a diagram that again, shows the effect of specimen compression on margin status and how a margin can be falsely positive due to the pancaking effect from compression..

For those who aren't into doing internet searches, see the following links-

The pancake phenomenon contributes to the inaccuracy of margin assessment in patients with breast cancer.Graham RA, Homer MJ, Katz J, Rothschild J, Safaii H, Supran S.Department of Surgery, New England Medical Center, Boston, MA 02111, USA.

http://www.ncbi.nlm.nih.gov/pubmed/12169349 

Understanding the mechanisms creating false positive lumpectomy margins

Presented at the Sixth Annual Meeting of the American Society of Breast Surgeons, Los Angles, California, March 16-20, 2005

http://www.radiologysource.org/periodicals/medima/article/S0002-9610(05)00557-X/abstract

  

sarangi

It will feel to the person who ahs this problem it will not display to outside so we have to check it out whether it has really afaccted to the body or not.After that we have to take action imidiately before it capture to whole body.

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