When will there be a definitive diagnosis?

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Szucs
Szucs Member Posts: 21
edited October 2018 in Surgery - Before, During, and After

8.9.2018: Primary Doctor

Right breast: a 2 cm, mobile, solid mass palpable right breast around 2 o'clock. Non tender. No erythema.

8.22.2018: Surgeon

RIGHT BREAST: Breast is free of nipple abnormalities; she has a dominant mass at the 2 oclock position measuring 2 cm; Mobile, and not fixed to chest wall. It is adherent to the overlying skin with erythema and early development of an ulcer. axillary and supraclavicular areas are unremarkable. Lymph nodes: no palpable supraclavicular or axillary adenopathy

LEFT BREAST: Breast is free of skin and nipple abnormalities; there is no dominant masses palpable. Diffuse nodularity with fibrocystic changes. Axillary and supraclavicular areas are unremarkable.

Lymph nodes: no palpable supraclavicular or axillary adenopathy

Assessment: Right breast invasive cancer.

9.21.2018: Surgeon

Pre-op for lumpectomy: EKG was taken and something wasn't quite right. They admitted her to the hospital, did a chest CT. Came home the following day and lumpectomy postponed.

9.28.2018: Surgeon

Chief Complaint: Known breast cancer, new skin nodule in left lower quadrant of abdomen

History of Present Illness: 90 year old woman with known right breast cancer. She was undergoing the pre-operative process when she was found to have large lung nodules/masses. About 2 weeks ago, she also noted a skin nodule in the left lower quadrant of the abdomen.

General appearance: alert, well appearing, and in no distress.

Abdomen: There is an approximately 2 cm nodule in the skin of the left lower quadrant. Hard and fixed to the skin

Impression: Skin nodule, likely metastatic disease

Plan: If the planned supraclavicular lymph node biopsy is non-diagnostic, can consider excision of this skin lesion

So as of right now, she is scheduled for an appointment on October 3, 2018 to biopsy lymph node(s).

I am her grandson, and I am starting to get very frustrated. The surgeon told her that he thinks it's lung cancer. Why can't they get to the bottom of this? Is it lung cancer or stage IV breast that has spread to the lungs? Breast cancer and lung cancer?

Why did her weight loss not trigger some further investigating? For probably more than two years she has had persistent Difficulty swallowing, coughing, always says she "has a cold."

7/16/2016 - 134 lb 7.7 oz (61 kg)
11/09/2016 - 132 lb 15 oz (60.3 kg)
2/20/17 - 129 lb 3 oz (58.6 kg) - upper res tract infection
4/6/2017 - 126 lb 8.7 oz (57.4 kg)
4/24/2017 - 123 lb 14.4 oz (56.2 kg) - DYSPHAGIA (DIFFICULTY SWALLOWING) - Primary
8/31/2017 - 113 lb 12.1 oz (51.6 kg)
1/17/2018 - 109 lb 2 oz (49.5 kg)

6 months and eleven days: 16 pounds in weight loss / 12.4% in unintentional weight loss within 6 months

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  • Georgia1
    Georgia1 Member Posts: 1,321
    edited September 2018

    Hi ther Szucs, and thank you for following your grandmother's care. I'm not a doctor, but the difference between breast cancer that spread to her lungs vs lung cancer that spread to her breast may be inconsequential here. And it also appears from this report that it has spread to the abdomen near her skin.

    The plan to check her lymph node is a good one clinically, and it may yield some answers. But if your grandmother is 90, the kindest thing may be no surgery at all. I'm sure that's hard to hear and I'm truly sorry you are dealing with this. But I think you will need to consult an oncologist, rather than a surgeon, to understand what's going on and advise on a plan going forward. You and your family will be in my thoughts.

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  • Szucs
    Szucs Member Posts: 21
    edited October 2018

    Georgia1, thank you for your response. Is seeing an oncologist before a surgeon considered the norm? I am baffled as to why it went from her primary doctor straight to a surgeon.

    She is tough as nails by the way, I don't know where it comes from. She is up 7am every day, usually goes to bed after watching one of the late shows. It's just weird how it went from her ultrasound where the doctor said, "it's probably nothing, but if it is, it's so slow growing that if would never affect you." Now it's stage IV and spread to lungs, or breast cancer and lung cancer. I'm not saying that I think that's what it is, this is what we are being told.

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  • keepthefaith
    keepthefaith Member Posts: 2,156
    edited September 2018

    I would suggest going to a multi-disciplinary facility, if she isn't already. The lung and skin nodule would have to be biopsied before they can figure out if it is a metastasis or lung cancer. I agree that an Oncologist should be consulted for further information and recommendations moving forward. She may need more testing. A second opinion may be in order also. She may do well on hormone therapy alone. Best wishes.

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  • Georgia1
    Georgia1 Member Posts: 1,321
    edited September 2018

    Seeing a surgeon first is standard, but that's for women under 70. Now there is good science to show that surgery can do more harm than good for older women, which is why I'd advise consulting an oncologist. I do wish you the best.

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  • Meow13
    Meow13 Member Posts: 4,859
    edited September 2018

    I would have her see an oncologist the biopsy should give them a better idea of what treatment should be given. I would avoid surgery unless it will help her be more comfortable. Did her weight stablize around 110 lbs?

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  • Sara536
    Sara536 Member Posts: 7,032
    edited September 2018

    Hi, Is your grandmother taking part in this discussion? Is she aware of the possible options?What is her opinion on next steps? Is she currently taking tamoxifen? If so, is it improving her quality of life or making her miserable? My MIL, at this age, was so miserable and tired of multiple medications and their side effects - so she demanded to be taken off the meds. All of them. She then proceeded to thrive, happily and in relative comfort for another 3 years!

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  • Szucs
    Szucs Member Posts: 21
    edited October 2018

    Oncologist seen today for the first time. Now it might not even be breast cancer...


    MEDICAL ONCOLOGY CONSULTATION

    Reason for Referral: breast cancer

    90 year old female

    Patient initially presented to general surgery in 8/2018 with abnormal R breast lump.

    Mammogram and ultrasound done 8/2018 confirmed 1.9cm oval mass in R breast, s/p biopsy

    FINAL PATHOLOGIC DIAGNOSIS
    BREAST, RIGHT, 2:00, 1.9 CM MASS (RADIOLOGY PERFORMED ULTRASOUND GUIDED
    NEEDLE CORE BIOPSY):
    - MODERATELY DIFFERENTIATED INVASIVE DUCTAL CARCINOMA.
    - NOTTINGHAM COMBINED HISTOLOGIC GRADE 2 OUT OF 3:
    - TUBULE FORMATION: 3 OUT OF 3.
    - NUCLEAR PLEOMORPHISM: 2-3 OUT OF 3.
    - MITOTIC COUNT: 1 OUT OF 3.
    - COMBINED SCORE: 6-7 OUT OF 9.
    - NO CARCINOMA IN SITU IDENTIFIED.
    - INVASIVE TUMOR SIZE: AT LEAST 1.4 CM.
    - LYMPHOVASCULAR INVASION: NOT IDENTIFIED.
    - NECROSIS: FOCALLY IDENTIFIED.
    - MICROCALCIFICATIONS: NOT IDENTIFIED.
    - BREAST RECEPTOR MARKERS (ER, PR, AND HER2): PLEASE SEE THE ADDENDUM REPORT.

    BREAST RECEPTOR MARKERS
    Date Ordered: 8/17/2018

    INTERPRETATION
    BLOCK:
    1
    ESTROGEN RECEPTOR (ER):
    Interpretation: Negative
    0% immunoreactive cells present
    Intensity of staining: Absent
    Scoring performed in invasive carcinoma
    No internal control is present; however, the external control tissue on the same slide is positive.
    PROGESTERONE RECEPTOR (PR):
    Interpretation: Negative
    0% immunoreactive cells present
    Intensity of staining: Absent
    Scoring performed in invasive carcinoma
    No internal control is present; however, the external control tissue on the same slide is positive.
    HER2 IHC:
    Negative (0, absent or incomplete, weak staining in <=10% of invasive tumor cells)

    8/27/18: discussed at breast conference. Recs: proceed with needle loc and SLNbx

    9/21-9/22/18: admitted for Afib

    CXR - hazy R lung base opacities, aspiration and/or pneumonia

    CT thorax no contrast - multiple lung nodules measuring up to 2.2 cm, mediastinal, hilar and supraclavicular LAD, pleural and pericardial effusions, R breast mass

    10/3/18, s/p US-guided bx of R supraclavicular LN

    FINAL PATHOLOGIC DIAGNOSIS
    LYMPH NODE, ULTRASOUND-GUIDED (RADIOLOGY PERFORMED) FINE NEEDLE ASPIRATION, SUPRACLAVICULAR AREA, RIGHT:
    - STATUS POST ULTRASOUND-GUIDED NEEDLE BIOPSY 1.9 CM MASS 2:00 RIGHT BREAST (BPMS18-17034)
    - EXTENSIVELY NECROTIC TISSUE SHOWING FEATURES OF METASTATIC, POORLY DIFFERENTIATED CARCINOMA (SEE COMMENT)

    COMMENT
    The findings are consistent with metastatic tumor. The overall morphologic as well as a minimal histochemical staining profile of this lesion is not specific and the site of origin of this lesion is not apparent The findings do not appear to support metastatic breast cancer. The possibility that this represents metastatic breast cancer is not completely ruled out but is not favored. Differential diagnosis includes, but is not limited to lung, proximal gastrointestinal tract, gynecologic or pancreaticobiliary tract. Two (2) other pathologists have reviewed this case and concur with this interpretation

    SUBJECTIVE/ROS:

    Weight loss, gradually, about 30lbs over the past year

    Progressive fatigue over the past month, but still remains relatively active

    Occasional SOB and dry cough

    Denies bone pain, headaches, dizziness

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  • Szucs
    Szucs Member Posts: 21
    edited October 2018

    Gen: elderly, pleasant, NAD

    HEENT: no palpable LAD

    CVS: irregularly irregular

    Lungs: decreased breath sounds at bases

    Abd: soft, NT, ND, +palpable hard mass 2-3cm in LLQ along surface of skin

    Ext: no edema

    Breast: left breast --> palpable hard mass, 3-4cm at 4 o'clock

    Labs:

    WBC'S AUTO 9.4 10/02/2018

    HGB 11.0 10/02/2018

    HCT AUTO 34.0 10/02/2018

    PLT'S AUTO 295 10/02/2018

    CREAT 0.80 09/22/2018

    ALT 12 04/11/2014

    AST 16 04/11/2014

    CA 8.7 09/21/2018

    ALB 3.3 09/22/2018

    No results found for this basename: ca153

    No results found for this basename: CA125

    No results found for this basename: IRON, IBC, FESAT, FERRITIN

    No results found for this basename: B12

    No results found for this basename: Folate

    No results found for this basename: HAV, HAVG, HAVIGM, HBSAG, HBVSAB, HBCAB, HCV, HCVPCR, HCVPCRQL, HCVPCRQN, HAVIGG, HCVPCRLOG, HAVAB, HBCIGM, HCVAB, HCVGENO

    Imaging: reviewed

    Pathology/Procedures:

    EGD, 5/2017:

    IMPRESSION:

    Mild gastritis and duodenitis s/p biopsies

    Unremarkable esophagus

    Suspect dysphagia is oropharyngeal in nature.

    FINAL PATHOLOGIC DIAGNOSIS
    STOMACH, ANTRUM AND BODY, BIOPSY:
    - GASTRIC OXYNTIC AND GLANDULAR MUCOSA WITH FOVEOLAR HYPERPLASIA AND MINIMAL
    ACUTE INFLAMMATION; SEE COMMENT.
    - NO HELICOBACTER, INTESTINAL METAPLASIA, OR DYSPLASIA SEEN.

    ASSESSMENT:

    90 year old female with hx smoking, hyperlipidemia, A.fib on pradaxa and aspirin, osteoporosis, osteoarthritis of bilateral knees

    R breast mass --> moderately differentiated invasive ductal carcinoma, ER/PR/HER 2 negative

    Pulmonary nodules, mediastinal/hilar/supraclavicular lymphadenopathy, pleural/pericardial effusion

    S/p R supraclavicular LN FNA --> metastatic poorly differentiated carcinoma, extensively necrotic tissue, with minimal IHC staining profile, not supportive of breast cancer. Ddx includes lung, proximal GI, gynecologic or pancreaticobiliary

    Explained to patient and daughter today that although we may be dealing with a diagnosis of triple negative breast cancer with visceral mets, this is not definitely supported on the recent R supraclavicular lymph node biopsy and limited IHC staining profile. There is a possibility that given her smoking history, she may have another primary malignancy such as lung cancer. This will guide management.

    PLAN:

    - CT neck/C/A/P to complete workup and evaluate for repeat biopsy for additional tissue

    - bone scan to r/o bone mets

    - genetics referral

    - baseline labs, including tumor markers

    RTC 2 weeks

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