Breast Cancer Diagnosis: Key Insights and Next Steps

Q: Breast Cancer Diagnosis: Key Insights and Next Steps

Dear Miss LiangRu：<br>1. <br>In medicine, the definitive diagnosis of a tumor is based on pathological examination. <br>A "smoother surface" observed during physical examination can only suggest that it "resembles" a benign condition, similar to how "women who breastfeed are less

Breast cancer concerns?

Blood Test Report
Age: 40
Department: Breast Surgery
Test Name Result Value Reference Value
W.B.C 4.91 4~10 10^3/uL
R.B.C 4.25 4~5.5 10^6/uL
Hb ↓ 11.4 12~16 g/dL
Hct ↓ 35.5 36~46 %
MCV 83.5 80~100 fL
MCH 26.8 26~34 pg
MCHC 32.1 31~37 g/dL
Platelet count 243 150~450 10^3/uL
Neutrophils 51.4 40~70 %
Lymphocytes 40.3 20~56 %
Monocytes 6.1 0~12 %
Eosinophils 1.6 0~5 %
Basophils 0.6 0~2 %
A-Lymphocytes 0 %
Bands 0 0~5 %
Metamyelocytes 0 %
Myelocytes 0 %
Promyelocytes 0 %
Blasts 0 %
NRBC 0 /100 WBC
APTT 27.7 23.9~34.9 s
Prothrombin time 10.1; INR: 0.98 8.7~11.9 s, INR
Pathology Report
25004C Surgical Pathology Level IV [Malignancy]
DIAGNOSIS: Left breast, excisional biopsy --- Invasive ductal carcinoma
Immunostains:
HHF-35: loss of myoepithelial cells in tumor cells
P63: loss of myoepithelial cells in tumor cells
CK34bE12: focal positive
CK5/6: negative
E-cadherin: positive
GROSS DESCRIPTION:
The specimen submitted consisted of a piece of breast tissue measuring 2 x 1.8 x 1.7 cm in size, fixed in formalin.
Grossly, it appeared mildly firm in consistency and grayish in color.
Representative sections were taken.

MICROSCOPIC DESCRIPTION:
Microscopically, the sections show invasive ductal carcinoma, grade 3, with the neoplastic cells arranged in small solid sheets and infiltrating the stroma.
High-grade ductal carcinoma in situ characterized by a solid growth pattern with comedo necrosis is present within the tumor.
The surgical cut margin is not free of tumor.

I apologize for my ignorance, but may I ask:
- Can you help me explain the content? Thank you.

- Is there any flaw in this report, or is there something missing? (During the physical examination, the physician mentioned it should be benign because the tumor surface was smooth, and after removal, it should be fine.
However, upon seeing the pathology report, he was surprised that it contradicted his initial assessment.
He wonders if this could be a misunderstanding, a testing error, or a sample mix-up, or what the situation could be.
He is very confused.
Are there any re-testing procedures?)
- If the results are indeed accurate as reported, what would be the most appropriate next steps in medical management?
- The physician mentioned that the breast must be removed because the tumor is too close to the nipple.
Are there any alternative solutions that do not involve removal? There is a lot of helplessness and anxiety...
If additional information is needed, I can provide it (ultrasound images and a video disc are available).
Thank you for your response, and I wish your family peace.

Liang Ru, 40~49 year old female. Ask Date: 2010/02/21

Dr. Wu Jingtang reply Breast and Thyroid

Dear Miss LiangRu:
1.
In medicine, the definitive diagnosis of a tumor is based on pathological examination.
A "smoother surface" observed during physical examination can only suggest that it "resembles" a benign condition, similar to how "women who breastfeed are less likely to develop breast cancer." This does not guarantee that breastfeeding women will not get breast cancer, but it significantly reduces the risk! This illustrates that the causes and manifestations of cancer are "diverse" and cannot be judged based on a single factor!
2.
Among the important findings in the test reports, the pathological report is crucial (the hematology report shows only a slight decrease in hemoglobin, which is still acceptable).
According to the pathological report, this is an invasive breast cancer approximately 2 centimeters in diameter, and there are still residual cancer cells in the breast after excision (this is acceptable as you underwent tumor resection surgery).
3.
Facing such results may cause you panic; however, before discussing the next steps, it is important to know that this is an early-stage breast cancer with a high cure rate! The next step should be surgery.
The total mastectomy you mentioned is one of the standard treatment methods.
If you wish to consider breast-conserving surgery, factors such as breast size and tumor location should be taken into account.
If, as you described, it is "very close to the nipple," then the difficulty of performing breast-conserving surgery will be high.
However, you can still discuss with your attending physician whether it is possible to attempt breast-conserving surgery first, and if residual cancer cells are found post-surgery, a second surgery can be performed.
This requires thorough communication and psychological preparation!
4.
Postoperative treatments such as chemotherapy, radiation therapy, hormone therapy, and targeted therapy should be determined based on the pathological report of the surgical specimen, as well as the status of hormone receptors and human epidermal growth factor receptor (which are not yet seen in your current report), along with abdominal ultrasound and bone scans (or possibly PET scans) for comprehensive consideration! Currently, you should prioritize the implementation of surgery! Some physicians advocate for chemotherapy first to shrink the tumor before surgery (which may increase the chances of breast-conserving surgery), and this can also be discussed!
5.
Most importantly, you must face this bravely and "do not hold pessimistic thoughts about a treatable disease." Wishing you success in your fight against cancer!
Sincerely,
Dr.
Wu Ching-Tang
Attending Surgeon, Taoyuan General Hospital, Department of Health

Reply Date: 2010/02/21

More Info

Understanding a breast cancer diagnosis can be overwhelming, especially when faced with complex medical reports and the emotional weight of the situation. Based on the information provided, let's break down the key elements of your blood test and pathology report, address your concerns, and outline the next steps in your medical journey.

Blood Test Analysis
Your blood test results indicate a few notable points:
1. Hemoglobin (Hb) and Hematocrit (Hct): Both values are slightly below the normal range. This could suggest mild anemia, which is not uncommon in patients undergoing treatment for cancer. Anemia can lead to fatigue and weakness, so it’s important to monitor and address this with your healthcare provider.

2. White Blood Cells (WBC): Your WBC count is within the normal range, which is a positive sign as it indicates that your immune system is functioning adequately at this time.

3. Platelet Count: This is also within normal limits, which is important for clotting and overall health.

4. Coagulation Tests: Your prothrombin time and INR are normal, indicating that your blood clotting ability is functioning well.

Pathology Report Insights
The pathology report indicates that you have invasive ductal carcinoma, which is the most common type of breast cancer. Here are some key points from the report:
- Grade 3 Tumor: This suggests that the cancer cells are poorly differentiated, meaning they look less like normal cells and tend to grow more aggressively.

- Invasive Nature: The tumor has invaded surrounding breast tissue, which is a critical factor in determining treatment options.

- Margins: The report notes that the surgical cut margin is not free of tumor, which means that some cancerous cells may remain in the breast tissue after surgery.

Addressing Your Concerns
1. Discrepancy Between Clinical Examination and Pathology: It’s not uncommon for a clinical examination to suggest a benign condition, especially if the tumor feels smooth. However, imaging and pathology provide a more definitive diagnosis. The nature of breast cancer can be variable, and it’s essential to rely on biopsy results for accurate diagnosis.

2. Re-testing and Second Opinions: If you have concerns about the accuracy of the diagnosis, it’s completely reasonable to seek a second opinion. This could involve having your pathology slides reviewed by another pathologist or undergoing additional imaging studies.

3. Next Steps in Treatment: Given the diagnosis of invasive ductal carcinoma, the standard treatment typically involves surgery. The recommendation for mastectomy (removal of the breast) is often based on the tumor's size and location, particularly if it is close to the nipple. However, breast-conserving surgery (lumpectomy) may be an option if the tumor can be adequately removed with clear margins. This decision should be made in consultation with your surgical oncologist.

4. Further Treatment Options: After surgery, additional treatments such as chemotherapy, radiation therapy, or hormone therapy may be recommended based on the tumor's characteristics and your overall health. These treatments aim to reduce the risk of recurrence.

5. Emotional Support: It’s normal to feel anxious and overwhelmed. Consider seeking support from counseling services, support groups, or talking to friends and family about your feelings.

Conclusion
Navigating a breast cancer diagnosis involves understanding complex medical information and making informed decisions about treatment. It’s crucial to maintain open communication with your healthcare team, ask questions, and express any concerns you may have. Remember, early-stage breast cancer often has a high cure rate, and there are many resources available to support you through this journey. Your health and well-being are paramount, so take the time you need to process this information and seek the support you deserve.

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