Radiologist v Surgeon

BlusteryDay · May 2020

I had a f/u dx mammo and u/s on a lump in my right breast that was previously thought to be a fibroadenoma (no biopsy, based on mammo and u/s) In 8-19.

Yesterday, Mammo and u/s...Radiologist immediately dictated and called my Gyn, GP, and surgeon. I was basically hurried through offices to get to surgeon for biopsy...who then read report which said Radiologist suspects triple negative breast cancer but surgeon says he thinks it’s benign, but scheduled Lumpectomy and possible sentinel node biopsy on Wednesday 5/27.

My lump grew from 5mm to 1.7mm from 8-19 to yesterday. I have small dense breasts. The lump is at 12:00 and is apparently “highly vascularized”.

None of my providers offered me the radiologist report, my NP said she thinks I need to wait to read it. I’m 50 and an RN and I’m worried. I know all of these people are trying to “cushion” me until we have a definitive answer, but dang! Can triple negative breast cancer be diagnosed from ultrasound and mammo???

ElaineTherese · May 2020

blusteryday,

No, triple negative breast cancer can't be diagnosed from ultrasound and mammo. It is the case that the radiologist may have a strong belief that he/she is seeing cancer, based on past experience. My radiologist told me that my images were consistent with cancer but that we had to wait to see what the biopsy said. In your case as well, the biopsy will provide the definitive answer. Also, your medical team -- by law -- should give you all the medical records you request. They are YOUR records. Please call the office and request your copy of the radiologist report. ((Hugs))

BlusteryDay · May 2020

Thank you! As an RN I was so confused by their mixed signals... praying for the best and preparing for the worst. I know I legally have access to my records and can access them as soon as they are unlocked on the hospital website (I’m a former clinical informaticist) but their blunt reactions were just very unsettling. My radiologist trainer at MD Anderson, in Houston...so I’m trusting that he has seen A LOT of breast cancer. I’m just going to keep praying for the best and pray I don’t need the sentinel node biopsy!

MelissaDallas · May 2020

All of that sounds really odd, and generally a core biopsy, guided by ultrasound, mammogram or MRI would be done prior to any surgery. Why would they schedule a sentinel node biopsy when they don’t even know if you have cancer or a benign mass?

exbrnxgrl · May 2020

I’m going to chime in too. Even if the radiologist felt strongly that it appeared to be cancer, how would he/she know the hormone profile and be able to guess it was triple negative simply based on imaging? Hormone profiles are determined via tissue samples, not imaging.I also don’t understand, as melissa Dallas stated, why anyone is talking about sentinel node biopsy when it hasn’t even been determined to be cancer yet

BlusteryDay · May 2020

I mentioned to the Surgeon when I got to his office that I had planned to consult with him, even before the mammo, and have the mass removed, regardless of benign v malignant because it’s uncomfortable, and visible. He said he is skipping the core biopsy and just going with a lumpectomy with clean margins, et. The whole day was very odd to me. Bear in mind that I’m in a small Texas town and my docs know each other and know me. I’m not sure if that has any bearing? It’s all very odd and unsettling.

BlusteryDay · May 2020

Thank you, both! I feel the same way...It’s crazy without a biopsy to be able to say “you have cancer” and even then...the type. I’ve researched the heck out of this and am just taking the wait and see what the biopsy result from Wednesday is.

MelissaDallas · May 2020

The thing is, the biopsy would provide valuable information prior to surgery, and conceivably if it is cancer chemo might be recommended for BEFORE surgery

BlusteryDay · May 2020

Thanks, MelissaDallas! That is excellent knowledge and I’m going to research that angle (because I’m an info maniac. I think I’m going to call the Surgeons office and request a “brake”. I feel like everyone is trying to jump steps quickly, for whatever reason, but it may not be in my best interest.

exbrnxgrl · May 2020

Would you consider going to a larger city for a second opinion? I’m just having a really hard time understanding how anyone can start talking hormone status based solely on imaging. If it were me, I’d be going for a second opinion ASAP. Take care

BlusteryDay · May 2020

Yes! This is actually at the forefront mind. I’m not too far from Houston so that is probably the route I’m going to take, especially if this surgeon insists on lumpectomy prior to biopsy. He did my biopsy 10 years ago, same anatomical area, but now I feel like I need a second opinion.

exbrnxgrl · May 2020

I’m so glad and, of course, Houston is a great place to go for that. I lived in Houston itself and alsoThe Woodlands (Conroe) many years ago. Have a good weekend.

Cricketdog · May 2020

I had just turned 50 and had a suspicious lump found with a regular mammogram. I went in for a core biopsy, which a new radiologist performed and botched. Results came back benign / regular fatty breast tissue, but he had a hunch it was cancer and tried to schedule me for surgery. I told him no way, that I wanted another biopsy. The senior radiologist called to tell me she was going to do a second biopsy and that a breast surgeon requires good biopsy results before surgery so they know what to do during surgery. She knew my first biopsy had issues because the mammogram showed a mass and no tissue in a mass comes back with biopsy results stating it’s just regular fatty tissue. The mass has to be one of five types of tissue, one type being cancerous.

So, all this to say I echo the comments on here. While maybe the rapid growth of your mass leads the radiologist to believe it is triple negative but a surgeon should require the biopsy results before they even talk with you and schedule you for surgery. Mine also sent biopsy tissue off for genetic testing before deciding treatment.

Hugs. Please keep us posted.

WC3 · May 2020

blusteryday:

When I had the imaging that lead to my diagnosis, it was pretty apparent it was cancer from the images. If you have ever seen those cross sectional educational drawings of a malignant tumor jutting up through and infiltrating layers of tissue, that is exactly what my cancer looked like on the ultrasound.

The doctor who had ordered the imaging was kind of old school and told me to skip the biopsy and go straight to a surgeon. That surgeon wanted a core biopsy before he did any surgery, and that is inline with modern standards of care.

If your lump is confirmed to be cancer and is triple negative or HER2 positive then they will likely want to do chemotherapy before surgery to make sure the cancer is responding to that particular chemotherapy. This allows them to find a regimen that works if the first one proves ineffective.

BlusteryDay · May 2020

Thank you all so much, I'm so glad I came here and asked. Even being an RN...my speciality is pediatric home health so I don't encounter this sort of topic. You all have given me a wealth of information to start arming myself and researching with. I have determined that I will NOT be having a “lumpectomy", but rather an “excisional biopsy", based on the description of the procedure...presumably because I stated I wanted the mass removed regardless of whether it was benign or malignant. Now, I understand this isn't the BEST route for my situation. Thank you all, again!

letsgogolf · May 2020

I am not a medical person but will tell you what my radiologist told me. After reviewing my repeated mammogram and first ultrasound, my radiologist came in and told me he was 99% sure I had breast cancer. I asked how he could know this prior to a biopsy and he pointed out several characteristics that my tumor had such as spiculation, calcifications, margins, acoustic shadowing and echo patterns. Apparently, what they see at that point can indicate the hormone status, etc. Spiculated tumors are very often hormone positive and tumors that are regular in shape (round or oval) are often high grade or triple negative. Certain features are even an indicator or high ki67. Maybe somebody else can expand on this a bit. Best wishes to you.

Salamandra · May 2020

I'm glad you are going for the second opinion. I do think that an experienced radiologist could be quite correct on his guess (though should admit that it can't be confirmed without pathology). But the question of whether to have chemo before surgery is not the radiologist's purview and it's important enough to be sure. I can see the rush to surgery given the rapid growth, and I hope you're able to get expedited review and consultation from a larger center. But my understanding is that in some cases even then chemo first is preferred, since it can give some more insight into the cancer and its susceptibility to chemo (and thus to risk management for metastasis).

Since you're in the healthcare field, you may know better avenues than I do. But my understanding is that your health insurance company may be able to help you arrange for a second opinion.

Also seconding that you should be able to get a copy of the report. I had a lot of issues getting my initial biopsy results (mostly due to tech communication issues between the two medical centers) and I ended up having to go in person, but once I went in person, they made me a copy and put it in my hand.

djmammo · May 2020

blusteryday

Pretty sure having a US guided core biopsy first is still standard of care before scheduling surgery. I don't believe any breast surgeon I have worked with did a lumpectomy without a dx of cancer on a needle biopsy. I have had a few general surgeons do that though.

ShetlandPony · May 2020

Or they might do a lumpectomy for a non-cancerous lesion that is typically benign but can sometimes harbor cancer, right? Like a radial scar or intraductal papilloma? My relative had core needle biopsies for these to find out what they were, then lumpectomies.

And isn't one reason they want the core needle biopsy first is so they can plan a sentinel node biopsy along with the lumpectomy if the lump is cancer? Because you can't go back and do that once the lump is gone because you can't trace the route from cancer to node, right?

Beesie · May 2020

Shetland, yes, a non-cancerous mass might be surgically removed but when surgery is done on a benign (or unknown) mass in order to remove it and assess whether the mass includes any cancer, the procedure should be called an "excisional biopsy" (or "surgical biopsy") and not called a lumpectomy. That said, because the procedures are so similar, some hospitals and doctors choose to (incorrectly) use the term "lumpectomy", often just for paperwork reasons, i.e. so that they only need one set of procedural documents rather than two.

Having a needle biopsy first does allow for a sentinel node biopsy to be done at the time of the lumpectomy, whereas it would not be good practice to perform an SNB with an excisional biopsy - given the lymphedema risks associated with node removal, nodes should never be removed unless it's known that the patient has invasive cancer. That said, an SNB can be done after a lumpectomy because usually the injections to trace the route to the nodes are placed around the nipple, not directly in the area of the mass. In fact it's normal practice for patients with DCIS to have a lumpectomy without an SNB; should invasive cancer be found in the final pathology, the SNB is done later as a separate small operation. The issue of not being able to do an SNB is only a concern after a mastectomy, when the whole breast is gone and therefore there is no where to make the injections.

As for another difference between a lumpectomy and an excisional biopsy, given cosmetic/appearance concerns following a lumpectomy, usually achieving wide surgical margins is not a goal of an excisional biopsy whereas it is a goal of a lumpectomy, when it's already known that the lesion is cancerous and wide margins are required.

Lastly, as others have mentioned, having a needle biopsy first allows for the consideration of doing chemo prior to surgery, which is appropriate in some situations.

Over the course of about 30 years, I had 3 excisional biopsies, at 3 different facilities. The procedures were always called excisional biopsies. I've never had a lumpectomy.

BlusteryDay · May 2020

UPDATE: GOT MY US AND MAMMO REPORTS TODAY!

My documents unlocked today on the hospital portal and I was able to download, and read them for myself. Based on what I'm reading... NO MENTION of TNBC, so I'm not sure WHY that was mentioned by the surgeon!? I'm a little angry about this!!! I've decided a needle biopsy to get a dx is what I need. I'm also going to get a second opinion from MD Anderson...I have great insurance, so why not!? All of your responses have provided me a WEALTH of information and information is power! Below are my mammo and US results from Thursday. Thanks again, EVERYONE! I hope this helps someone in the future not make the mistake that I almost made!

Mammogram REPORT

Bilateral digital diagnostic mammogram with 3-D tomosynthesis evaluation

Clinical indication: The patient is a 50-year-old female being further evaluated for area of right breast palpable concern. The left breast was also subjected to mammography as the patient was due for her annual screening mammogram.

Technique: CC, MLO and ML views of the bilateral breasts were acquired using digital technique. The study was interpreted with the benefit of CAD technology.

Three-dimensional tomosynthesis was applied to all views.

Comparison: Bilateral digital screening mammogram, October 11, 2018.

Findings: The breasts are composed of heterogeneously dense fibroglandular tissue, which may obscure small breast masses. The included axillary regions are benign. There is a palpable marker at the 12:00 position of the right breast, 6.5 cm from the nipple, denoting site of right breast palpable concern. There is a 1.8 cm sized isodense round mass with indistinct margins (margins confirmed on three-dimensional tomosynthesis evaluation) at the 12:00 position of the right breast, 7 cm from the nipple, that accounts for the area right breast palpable concern. A targeted ultrasound examination of the right breast and axillary nodal basin is recommended for further evaluation.

There is no suspicious calcification in the right breast. There is a postbiopsy marker clip at the 12:00 position of the right breast, 6 cm from the nipple, denoting site of previous benign right breast biopsy. There are is no dominant mass, architectural distortion or suspicious calcification in the left breast to suggest malignancy. There is no pathologic skin or nipple alteration.

IMPRESSION:

1. There is no mammographic evidence of malignancy in the left breast.

2. Right breast mammographic abnormality as detailed above with above recommendations.

ACR BI-RADS Category 0: Incomplete examination.

Management: Need additional imaging evaluation.

Ultrasound REPORT

Targeted ultrasound examination of the right breast and axillary nodal basin Clinical

indication: The patient is a 50-year-old female being further evaluated for right breast mammographic abnormality.

Technique: An additional MLO view of the right breast was acquired using digital technique. MLO.

Comparison: Bilateral digital diagnostic mammogram obtained the same day. Findings: Further evaluation was performed on the 1.8 cm sized isodense round mass with indistinct margins at the 12:00 position of the right breast, 7 cm from the nipple, seen on bilateral digital diagnostic mammogram obtained the same day. This correlates with a wider than tall angularly marginated hypoechoic mass at the 12:00 position of the right breast, 5 cm from the nipple, measuring 2.5 x 1.3 x 1.6 cm in size. This mass demonstrates internal vascularity to mild hyperemia on color Doppler analysis. This mass also demonstrates increased through-transmission. This mass is located 0.2 cm deep to the dermis. There is no pathologic skin thickening. This mass is located at least 1.5 cm superficial to the right pectoralis major muscle. The remaining evaluated right breast demonstrates normal heterogeneously dense fibroglandular tissue. No pathologically enlarged right axillary lymph nodes are identified.

IMPRESSION: 1. Suspicious right breast masses detailed above. An ultrasound guided core needle biopsy is recommended. Recommendation for ultrasound-guided core needle biopsy was discussed with the patient.

ACR BI-RADS Category 4C: Suspicious abnormality.

Management: Tissue diagnosis.

exbrnxgrl · May 2020

So glad that you were able to get the report and a trip to MD Anderson sounds like a very good plan. The reason there is no mention of triple negative or any other hormone profile details is because those things cannot be determined by imaging! It would kind of be like determining someone’s blood type by simply looking at their blood. That’s why I thought it strange that anyone would say that based on imaging alone. Wishing you all the best

Radiologist v Surgeon

Comments

Categories