Help with questions to ask breast surgeon

Hi 071655:

If you have not had a biopsy yet, I would think that is the next step based on this page at BC.org:

http://www.breastcancer.org/symptoms/types/inflamm...

The above page indicates a skin punch biopsy or ultrasound-guided core needle biopsy might be recommended.

Here is a page which briefly discusses various biopsy techniques, including core-needle biopsies and the use of ultrasound for guiding same. Be sure to scroll to the very bottom of the page for some good sample questions about biopsies at the bottom:

http://www.breastcancer.org/symptoms/testing/types...

BarredOwl

Hi 071655:

Thanks for the update. I do not mean to second guess your doctor or your decision, but have some thoughts for you. I note your earlier post saying:

"I have an enlarged/swollen breast, a red rash area that is dimpled, breast is hot to the touch, skin thickening and some retraction. I know not everyone has the same symptoms. Some have less and other have more. I just want the surgeon to check and do everything he can do and find nothing wrong and pat me on the head and send me home. . . .

The odds that it is IBC are very slim for which I am holding on to that fact. [But an] infection has been ruled out."

If an infection was ruled out, are you saying you have you already been to a dermatologist? If so, and no skin condition has been diagnosed, then I am not sure what explains the symptoms, including retraction (is that of the nipple?). As you said, you are "still wondering what the heck is going on."

I also note your comment "if there is nothing there to biopsy why bother?" Is that based on the surgeon saying "he said he could do a skin biopsy, but he is positive it would come back negative"? My reaction to that is that there is no way for a clinician to know in advance whether a biopsy will come back positive or negative. I think he is really just saying this based on his clinical assessment, that he does not think your symptoms are IBC, because he does not see any orange peel appearance including skin puckering or skin thickening. He may be looking at other things as well, such as extent of involvement.

So, if you have already been seen by a dermatologist and they have no answers for you, then I do not see a second opinion as wasting another doctor's time, particularly as IBC seems difficult to diagnose and varies in presentation, and the "peau d'orange" or orange peel appearance is not always present.

I saw this information from MD Anderson, although the speaker appears to be a breast radiologist, not a breast surgeon:

http://www.mdanderson.org/transcripts/clinical-dia...

The interesting part is this:

"Another important issue to note, that although many of these cancers can be mammographically occult, MRI can detect abnormalities in the involved breast the majority of the time. So "what should a patient do who has symptoms of inflammatory breast cancer, has been given antibiotics, is not responding, and has a negative mammogram?" Go back and request for additional imaging, ultrasound or MRI, and a biopsy of the affected area to truly rule out inflammatory breast cancer without delay."

If you do see worsening of symptoms or increasing extent, please do not wait for the whole three months for follow-up with a breast surgeon.

If you have not seen a dermatologist yet, then that is a good next step like Kicks said. If they can't see you quickly, ask to be placed on the waiting list in case there is a cancellation.

If no skin condition has been/can be diagnosed, or dermatological treatments have not/do not lead to improvement in the short-term, it would not seem unreasonable at all to seek a second opinion as a next step, along the lines your husband has suggested.

BarredOwl

[Edited to add: As you know, I am just a patient/layperson. Although core-needle biopsy cannot be guided by mammography or ultrasound when negative, it seems like a skin punch biopsy or MRI-guided biopsy (if there were findings on MRI) would be possible options.]

Hi 071655:

I feel a little better that the inversion is not new, but I am just an IDC patient, so I don't know what the other symptoms or on/off aspect means.

One thing I would recommend is asking for a copy of the radiologists' original written reports for the mammography and ultrasound for your files. You could also check that the radiologists' conclusions and recommendations are consistent with the breast surgeon's.

Just to clarify, the quote I provided suggested that sometimes IBC is "mammographically occult", meaning it cannot be seen by mammogram. The imaging options are then ultrasound, which you already had, or MRI. MRI is the most sensitive of these techniques.

If you need a referral to see the dermatologist, but can't get one from the route proposed above, maybe the breast surgeon could to refer you to a dermatologist.

If at some point, you do seek a second opinion, it could also include an independent review of all imaging to date by a second radiologist, as well as a consultation with another breast surgeon. Interestingly, my second opinion confirmed the pathology, and surgical advice, but not the imaging. The second radiologist felt there was a suspicious area on the non-affected side, performed a further diagnostic mammogram, and recommended a biopsy, which found DCIS (that changed my treatment from unilateral to bilateral mastectomy).

Even as you continue to pursue answers with a dermatologist or possible second opinion, you are not crazy, but smart to follow up until you are no longer asking yourself "what the heck is going on"? This is so even if this turns out to be something totally benign, which I hope it is!!

Good luck!

BarredOwl