The Pathology Report

Bo and I returned to the surgeon's office on Thursday, and I was able to have two of the four drains removed. I asked Donna, the nurse practicioner, if it would hurt, and she said she doesn't get many complaints. That is because people are apparently speechless after stifling back their screams of agony! She first had to wrestle with the tight stitches Dr. H had placed to hold the drain tubes in place, and after she was finally able to snip those, she then pulled the drain mechanisms, all six inches worth, out of my body. Ouch! I didn't want to be among the few complainers, so I just grimaced furiously and squeezed the daylights out of Bo's hand.

I have an appointment on Monday to remove the other two, provided the amount of fluid draining from each is fewer than 30 ccs in a 24 hour period. At this point, it looks like I am going to have to reschedule as the drain tube closest to the area where the lymph nodes were removed is still draining in excess of 60 ccs daily. I have mixed emotions about that appointment. I want those suckers out for sure, but I just don't relish the removal process.

When I first arrived and as the nurse's aid checked my blood pressure, she mentioned that the pathology results were back. Then Donna walked in, and I was trying to read Donna's demeanor and expressions as she was doing her thing with the drain tubes. Was she artificially cheerful or just her characteristic gregarious self? Did she seem nervous or was she just intent on causing me as little physical pain as possible as she removed the drains? Here I was driving myself crazy, making interpretations about the pathology results from Donna's behavior, and it turns out that Donna didn't even know they were back. She was seeing the results herself for the first time as she read them to me and Bo.

Basically, Donna's summary was that the cancer had responded to the chemo and that I had two out of 27 lymph nodes test positive. I had some questions she was unable to answer, and I asked if I could see Dr. H. She said that he was busy preparing for a big presentation and that he was soon undergoing surgery himself and as such would be unavailable for awhile. She said because my case was an unusual one (not a distinction one wishes to have at time like this), that it would most likely go before the tumor board again for review, but she was thinking radiation would be in my future. (By unusual, I believe she was referring to the seemingly sudden onset and aggressive nature of the cancer. ) She offered me a copy of the pathology results and told me she would call me about the tumor board, as she didn't know who would present the information in Dr. H's absence.

So, I walked out of the office, report in hand and nerves on edge. Remember that whole new attitude thing I wrote about a couple of days ago with such bravado? It had completely disappeared as I read the report and interpreted the medically terminology as negatively as I possibly could for reasons that defy explanation. Despite my generally optimistic outlook, in the absence of information, I have this debilitating habit of always assuming the worst. I was approaching the ledge, and Dr H was not available to pull me away (or push me over).

It was about 4:30 p.m., so I called Dr. P's office, knowing that if I didn't reach her that afternoon, she wouldn't be available again until Tuesday. I couldn't go the whole weekend applying my own interpretations to the report. The receptionist told me that she would relay the message to Dr. P but because it was so late in the day, she didn't know if Dr. P would call me back. I left my cell phone number, optimistic that Dr. P would sense my state of mind and respond in her usual competent and compassionate fashion. I also called my brother, John, whose good friend is an oncologist, to see if I could fax the results to Joe in the morning for deciphering. Then I waited.

The report pretty much confirmed much of what we already knew about the type of cancer: Infitrating ductal carcinoma, well differentiated, estrogen receptor positive, progesterone receptor negative, her-2/neu negative. It also indicated, among other things, the following: there had been prominent therapy effect, two out of 27 lymph nodes tested positive for metastatic carcinoma (largest focus 7 mm), the margins were negative for malignancy, the size of the invasive component was 1.8 cm, the tumor was multicentric with multiple foci of residual infiltrating ductal carcinoma in upper outer, lower outer, and lower inner quadrants.

See what I mean? What exactly does all that mean? What I did know is that the tumor at the time of the initial diagnosis, measured 3.5 cm. by ultrasound imaging. After the first four chemo treatments, it was 2.6 cm, and it was now measuring 1.8 cm. so I interpreted that favorably; although, I wish it had totally disappeared. There were other suspicious areas found by the initial ultrasound, but they were never biopsied since I was having a mastectomy, and from a treatment standpoint, it really didn't make a difference if they were cancer or not. Turns out they were cancer afterall. (I keep going back to how a mammogram in March could have possible missed multiple tumors that had infiltrated three out of four quadrants of my breast! I guess we will never know.) I took the word "residual" to be a positive thing, but again, I wish that the cancer had been limited to the one quadrant and that it had disappeared altogether.

I was very discouraged that I had two lymph nodes test positive, even after all that chemotherapy. I wasn't sure how to interpret that since only one lymph node was detected during the initial ultrasound and it had tested positive, but the subsequent PET scan and MRIs had detected no lymph node involvement. Had it spread while I was undergoing chemo?

The pathology for the left breast showed microcalcifications and atypical ductal hyperplasia - aka - precancer. We make a number of significant decisions in a lifetime. Many times we never know if we really made the right decision. Many times we convince ourselves we made the right decision because things turn out okay and we have no way of ever knowing how things would have ended up if we had taken a different course of action. In this case, I have validation that I absolutely did the right thing and that my intuition was right on. I don't think I ever would have second-guessed the decision to prophylactically remove the left breast, but it sure feels good to have confirmation that I most likely averted a second trip of this life changing journey I plan to travel only once!

My cell phone mercifully rang during dinner, and it was Dr. P. Thank God for her! She did a very effective job of pulling me back from the ledge. In fact, she was enthusiastic about the results, saying that we had "nuked" the cancer and that what remained was "swiss cheese." As many times as I read that report, I never saw the words "nuked" or "swiss cheese", so I really appreciated her interpretation. She said that it would have been great to have a complete response, but we knew that wasn't the case all along. She was glad to see that only two lymph nodes tested positive, stating that the risk of recurrence is much lower when fewer than three lymph nodes test positive. She mentioned two former patients with inflammatory breast cancer, a more serious type of breast cancer, who both had two lymph nodes test positive following neo-adjuvant chemotherapy, and years later, are still cancer-free. She also believes the cancer is affected by estrogen and that hormone therapy will be very effective for me.

I felt so relieved after speaking with her. I have a large list of questions, as she has come to expect, for my next appointment with her on November 21, but for now, I am content just to hear that the pathology results were encouraging to her. So my kick-butt attitude was restored during our second course of dinner that evening, as its vulnerability was also acknowledged.