MRI Results, Consultation with Surgeon

AFFIRMATION
Today I went for a consultation with the surgeon, Dr. Lydia Schrader. Instead of unflattering muumuus, she offered a very feminine cape, which I am modeling here:

Upon meeting her for the first time, Dr. Schrader asked why I had come in today. I said I hoped to hear the results of my MRI. She asked, "What else?" I said I also hoped I would hear what my options are for surgery. "Surgery for what?" she pressed. I thought it was odd. Clearly she knew why I was there. Back and forth we went until it was boiled down to its essence. She wanted to hear me say, "I have breast cancer." It was interesting. She must deal with a lot of people who are either poorly informed or in denial. I am neither poorly informed nor in denial, but still it felt somehow satisfying to be forced to say it outright.

My name is LaDawn and I have breast cancer.

I hope as you have followed my story you have seen that I like to infuse humor into the narrative. I certainly hope I have made people laugh, even though (and especially because) this is such an unfunny business. Today though, there are only two things to laugh about.

• I was informed today that the MRI detected elevated numbers of a protein called HER-2 in the duct cells of my right breast. I was also informed there is a suspicious mass in my formerly 'unremarkable' left breast, to which I responded, "Her, too?" 
• While informing me that my right nipple cannot be saved, Dr. Schrader said the entire areola "lit up" on MRI. My response (of course) was, "Yes, it tends to have that effect on people."  

Cancer is hilarious.
(Not really. Shhhh.)


The Unfunny Parts
The presence of HER-2, despite its funny name, indicates that my cancer is extremely aggressive. Prior to 10 years ago or so, a finding of elevated HER-2 cells meant a dramatic drop in life expectancy. Fortunately, there is now a drug that targets HER-2 specifically, and gets great results. So now, despite it being an indicator of terrible news, it is actually a lucky type of cancer to have, because not all types have targeted drugs that get such successful results. I don't know yet what the drug is called or when I'll get it, but I'm happy to know it exists. Yay for cancer research!

A second tumor was found in my right breast. Because it is now definitely a multicentric (having more than one center) cancer, it is very likely that it has affected my lymph nodes. In fact, the MRI found "mild asymmetry" in at least two of my nodes. Dr. Schrader said there was a possibility those asymmetries were due to swelling and bruising from the biopsy I had last week. I'd like to cling to that hope, but I think it's unlikely. To find out for sure, a biopsy of those nodes has been ordered for February 4th, which is 10 days away.

They also want to do further ultrasound imaging and possible biopsy of the mass found in my left breast. I am going to ask about opting out of the biopsy on the left breast. I have decided that I absolutely want a bi-lateral mastectomy, so undergoing repeated stabbing by a sharp instrument just to find out what kind of mass it is seems unnecessary.

The doctor who wrote the report (a radiologist named Dr. Schlund) also recommended a PET CT, which I assume would show whether cancer has spread to other organs/systems. But a PET CT was never mentioned in my consultation with Dr. Schrader today. I'm not sure why, and that will definitely be a question I'll bring up the next chance I get.

Something that was discussed was what a statistical rarity I am. The chances of a woman age 40-45 getting the type of cancer I have (estrogen negative, progesterone negligible, HER-2 positive) is only 2%. I'm in the 2%! Finally, something besides Momonism I have in common with Mitt Romney. Ha!

Even though it's already clear I have this breast cancer, they want to find out if I had an increased risk of getting it due to heredity. Apparently, breast cancer comes about either because of environmental factors, chance mutation, or heredity. They did a blood test on me to find out if I am a carrier of either of the genes they have isolated as markers for breast cancer. If I am, we can take precautionary steps for our children, who would have a 50% chance of also carrying the gene/s.

I mentioned in an earlier post that I had no family history of breast cancer. Well, I've recently learned that one of my aunts had a breast surgery about 9 years ago. Perhaps if I had known of that history, I would have been less reluctant to start screenings. Take away: If you have breast cancer, tell your siblings and offspring. Results of the genetic test I took should be back in about 10 days.



One Possibility
I do know I'll be having a double mastectomy. When and how are not so sure. Many are asking me why further biopsies and screenings are requested, when it seems surgery should be the immediate next step. Here's what I have gathered about that (remember this is Tetris):

Dr. Schrader says that they want to do node biopsies because they want to know as much as they can before operating. What they do in surgery will depend on what they find in these screenings. She also said that depending on the findings in biopsy, my treatment plan may include pre-surgical chemo and/or radiation, and that is another reason surgery is not the next step.

We heard about a few surgical options today. One of them intrigues me, but I don't yet know if I am a candidate for it. It is a true one-stop-shopping experience. Total mastectomy is performed, then fat is harvested from the abdomen, transplanted to the chest and revascularized. It's a pretty intense surgery, and would require a long hospital stay in San Francisco, but dang! Mastectomy, boob job, tummy tuck, bada bing, bada bang, bada boob. I dig!

Also I've been very moved by the fact that my sisters and friends have offered to be fat donors for this procedure should I undergo it. Such selfless generosity! Ha!

One thing's for sure: I want these puppies off of me yesterday.



For the Deep Reader
If you're interested in MRI science, if you'd like to see an example of the difficulty posed by lack of punctuation, or if you're just really into me, here is a transcript of the important parts of my MRI report, along with annotations by me on what I think it all means. Dr. Schrader called Dr. Schlund (the one who wrote my MRI report) 'gifted,' but I see no sign of it in terms of his ability to write. It took a lot for me to decipher this report, including the help of my nurse-sister and doctor-friend (thanks, ladies!). 

MRI REPORT

IMPRESSION:
1. Composite findings fully compatible with extensive and multicentric neoplasm which is both reflected in high grade ductal carcinoma evidenced in extensive pleomorphic calcifications without MRI enhancement and multicentric enhancing poorly differentiated HER-2 amplified invasive carcinoma both at the site of biopsy proven index lesion 8 o'clock posterior third right breast and also suspected in a smaller second lesion in the 1 o'clock aspect middle third right breast.

What I think it means: What we saw on MRI corroborates what was found at biopsy, with the additional finding that a) you have a lot of HER-2 receptors (bad news but very treatable), and b) there's another mass we didn't know about.

2. Mild asymmetric nodal prominence of the right axilla and right subclavicular regions concerning for adenopathy and nodal involvement.

What I think it means: There's a weirdness about the shape of the lymph nodes in your armpit and below your collar bone that suggest disease.

3. Equivocal regional progressive enhancement upper outer quadrant posterior third left breast which by kinetic footprint would suggest a size of 16x5x12 mm and repeat second look ultrasound is recommended for this location.

What I think it means: There's an area in your left breast that is arguably suspicious, and it's even bigger than the known mass on the right. You should get it checked out.

4. BI-RADS Category 6, known neoplasm right breast.

RECOMMENDATION:
1. PET CT

2. Second look ultrasound to include upper outer quadrant posterior third left breast and nodal basin right breast to include supraclavicular, infraclavicular and right axilla.

What I think it means: They will be jabbing you with pencils again, both sides this time, and will be testing the mass on the left and the nodes on the right for the presence of disease.

3. Referral to comprehensive breast care at this time for integrated consultation to include medical oncology, radiation oncology and breast surgery.

[Then a bunch of other stuff about how it was all done.]

RIGHT BREAST:
In keeping with the biopsy findings there are paramagnetic artifacts associated with the biopsies and mild postbiopsy infiltrative inflammatory change. At the site of index lesion 8-9 o’clock posterior third right breast there is a rapidly enhancing mass with washout kinetics measuring 14x10x14 mm consistent with the ultrasound. For the extensive distribution of pleomorphic calcifications consistent with high grade ductal carcinoma in situ the MRI is disturbingly quiet for the extent of calcifications which are without significant enhancement. That said however there is a separate unbiopsied site of ill-defined rapid enhancement and washout kinetics measuring 7x5x5 mm in the 1 o’clock aspect middle third right breast fully consistent with multicentric invasive cancer. Additionally there is mild right axillary and infraclavicular nodal prominence or adenopathy right side. There is no internal mammary chain adenopathy.

What I think it means: We saw the titanium clips left by the previous biopsy. We saw that your breast is bruised and swollen from the biopsy. We found what mammo and sono found, an invasive mass at 8 o'clock, and we confirm that it measures 14x10x14 mm. For as wide spread as the DCIS calcifications were on mammo, we see very little of them on MRI, and that's weird. BUT there's another mass that also looks invasive at the 1 o'clock position, AND there's either a weird protrusion or disease in the armpit and collar bone area lymph nodes.

LEFT BREAST:
In the axillary tail or posterior upper outer quadrant left breast there is a predominant area of progressive enhancement which in correlation to mammography is without definable architectural distortion and on ultrasound of January 8th there was no sonographic finding for which this may be a regional inflow enhancement artifact although a second look ultrasound would not be unreasonable and this is graded as BI-RADS Cateory 0, indeterminate for which second look ultrasound is recommended.

What I think it means: We see something fishy in the left breast, it could just be a 'regional inflow enhancement artifact' (something showing up because of the dyes we injected??), but you should check it out anyway by having another ultrasound.





GRATITUDE
Kudos again to my wonderful network of support, which, amazingly, seems to be expanding. Honorable mention goes to Suzie, who came bearing cake and elbow grease, and who has lent us a vehicle since one of ours very rudely went kaput mere days after being paid off and without any consideration for cancer.

But the prize goes to this guy, for being ever by my side, for laughing when I laugh and holding me when I cry, and most especially for wearing this shirt to our surgical consultation today:

PLEASE COMMENT
I'd love to know who's reading and hear from you. If you take the time to comment, you will be bringing joy to someone with some pretty serious-@ss cancer. And if you can make me laugh, well that'll probably give you stars on your chart in heaven.