Posted by: healingseeker | January 7, 2010

My Pathologist Report is in with a confirmed Diagnosis of Malignant Breast Cancer

Please note: This is what I sent to my dearest friends and family members:

7 January 2010

Dear Family and Friends,

Okay, my pathologist report finally came in one day later than I originally expected it.

Background update:

21 Dec. 2009: Discovered lump in left breast

28 Dec. 2009: Went to Health Department to have it examined. They detected that it was 3×5 inches and possibly bigger and it appeared to be quite serious.

4 Jan. 2010: Diagnostic Mammogram. Result: 1 chance in 10,000 it was benign. 9999 chance in 10,000 it was malignant breast cancer. The good news is that it appeared to be localized and not in my lymph nodes.

4 Jan. 2010: On the same day, they conducted my breast tissue biopsy. The official name for this process is Stereotactic Breast Biopsy.

Rhode Island Hospital.org gives this definition: “A stereotactic breast biopsy is a test that uses a special computer to guide a needle to an abnormality seen on mammography. A large percentage of these abnormalities are benign and present no health risks. This biopsy is a non-invasive, accurate way to obtain the tissue sample required for diagnosis. The procedure requires little recovery time and there is no significant scarring to the breast.”

Here is a video that shows the table a patient lies on during the biopsy and a brief description of the process. YouTube Video – Stereotactic Breast Biopsy

Dr. D’Angelo finished my biopsy at 4 pm Monday. He indicated that I should receive the results by Wednesday around noon. Instead, it didn’t happen until today, Thursday, at 1:00.

The information got faxed over to the Health Department. They read the scores over the telephone. They did not, however, know what any of these scores meant. I will tell you, after-the-fact, that the following scores simply gives my oncologist and surgeon treatment information about whether I will need chemo, radiation, surgery, or hormonal therapy. It does not reveal what stage cancer I have. So don’t get worried or excited.

Quoted from my Pathology Report:

  • Pathology Report diagnosis: Left Breast, Core Biopsy: Invasive Mammary Carcinoma
  • My invasive tumor shows both lobular and ductal features.
  • The tumor has a Nottingham grade II (tubule formation score = 3, mitosis score = 1, nuclear pleomorphism score = 2).
  • Tumor is present in all core biopsy fragments, with the largest dimension of 1 cm.
  • Please note: The final tumor grade and size should be determined on the final excision/mastectomy specimen.
  • ER, PR and Her-2 studies have been ordered and the report will be put in an addendum.

End of Quoted Section.

OncoLink.org explains Nottingham grade scores in a way I can understand:

Kevin R. Fox, MD, Assistant Director, Clinical Affairs and Associate Professor of Hematology/Oncology at the Abramson Cancer Center of the University of Pennsylvania, responds:

  1. “The Nottingham histologic score is simply a scoring system to assess the “grade” of breast cancers.
  2. It is a total score based on 3 different sub-scores.
  3. The 3 sub-scores are assigned based on 3 components of how the breast cancer cells look under a microscope. (The details of these 3 components are not critical for you to understand).
  4. Each of the 3 components is assigned a sub-score of 1, 2, or 3, with 1 being best and 3 being worst.
  5. Once the 3 sub-scores are added, a Nottingham score is obtained: the minimum score possible is 3 (1+1+1) and the maximum possible is 9 (3+3+3).
  6. A histologic grade of III is assigned to any patient with a Nottingham score of 8 or 9.
  7. Grade I refers to Nottingham scores of 3, 4, and 5, while Grade II refers to Nottingham scores of 6 and 7.
  8. In the end, the Nottingham score and histologic grades are not very useful in the big picture, as they do not alter final overall treatment recommendations.
  9. High-score cancers tend to relapse more often than low-score cancers.
  10. Ultimately, however, we don’t use the score in making clinical decisions.”

My Nottingham Score is a 3 + 1 + 2. Total of 6. So I have a Nottingham Score of Grade II.

Back to that quote from my Biopsy report:
The tumor has a Nottingham grade II (tubule formation score = 3, mitosis score = 1, nuclear pleomorphism score = 2).

Access Excellence.org defines MITOSIS as: “Mitosis is a process of cell division which results in the production of two daughter cells from a single parent cell. The daughter cells are identical to one another and to the original parent cell.”

My biopsy doctor, Dr. D’Angelo, said this simply is information the oncologist and surgeon will need to help determine my treatment.

Wow! I just found the most helpful resource on Health Central.com: Reading The Pathology Report – A Layperson’s Guide To Understanding Your Breast Cancer Diagnosis

It literally walks you through the entire report, step by step. The author of this report is PJ Hamel, a Breast Cancer Survivor. Her mantra is: “Cancer is a rock in the path; step over it, the path will still be there.” Love it!

PJ Hamel states, “There are 14 identified types of breast cancer; the major ones are ductal carcinoma in situ (DCIS); lobular carcinoma in situ (LCIS); infiltrating ductal carcinoma (IDC); infiltrating lobular carcinoma (ILC); and inflammatory breast cancer (IBC).”

My pathology report indicates I have lobular and ductal features. She said the main words to watch for are INFILTRATING or INVASIVE versus IN SITU. Mine is Invasive. Apparently, that means the same as Infiltrating. So I guess I have a combination of IDC and ILC. IDC is apparently more common than ILC.

For extra reading, here is how the two are described in layman’s terms on Breast Cancer About.com:

Invasive Lobular Carcinoma – ILC Breast Cancer
Invasive Ductal Carcinoma – IDC Breast Cancer

  • Back to PJ Hamel, she states that “infiltrating means it’s started to spread; not necessarily outside your breast, but beyond the milk ducts or lobules where it started.
  • In situ means it hasn’t yet spread outside the milk ducts or lobules. In situ cancers are often called ‘pre-cancers’; nevertheless, they’re viewed as cancer and treated as such.”
  • So the term “in situ” will not apply to my situation.

The tumor has a Nottingham grade II (tubule formation score = 3, mitosis score = 1, nuclear pleomorphism score = 2).

  1. Now my Nuclear grade was 2. What does that mean?
  2. PJ Hamel explains, “Nuclear grade: Cancer cells, like all cells, are run by a command center called the nucleus. Cells with a small, regularly shaped nucleus look more like normal cells; they’ll be given a score of 1. Cells with a large, irregularly shaped nucleus will be given a score of 3. Cells in between those extremes receive a grade of 2. The larger and more irregular the nuclei in the cancer cells, the more aggressive and dangerous they are.”
  3. So I am halfway in-between when it comes to that aspect of my cancer.

The tumor has a Nottingham grade II (tubule formation score = 3, mitosis score = 1, nuclear pleomorphism score = 2).

  1. Now my Mitotic grade was 1. What does that mean?
  2. PJ Hamel explains, “Simply, the number of cancer cells that are actively dividing. Fewer cells dividing = a score of 1; more cells, 2; even more cells, 3. The more cells dividing, the more aggressive the cancer.”
  3. Okay, so I have fewer cells dividing. That makes it sound like my cancer is not that aggressive. The fact that Dr. D’Angelo said that it appeared my lump was localized and not yet in my lymph nodes supports that conclusion.

PJ Hamel does not appear to address the tubule formation. And since I do not yet have the rest of my pathology info, I will come back to read and process the rest of her article at a later date.

The tumor has a Nottingham grade II (tubule formation score = 3, mitosis score = 1, nuclear pleomorphism score = 2).

One site I found on the internet (blurtit.com) states that the tubule formation grade has to do with “the percentage of tumor cell present in tubule formation. The Tubule Formation score 1 means that 75% of the cells are in tubular formation which is good and a score of 3 means less the 10% cells in tubular formation which is bad.”

So according to that source, my score of 3 on tubule formation is NOT good news.

A lot of the sites spoke way over my head. I did find this little ‘light at the end of the tunnel’ approach that relieved me somewhat from an Abstract on Nature.com:

“A breakdown analysis as a function of the three components showed that neither tubule formation nor nuclear pleomorphism was associated with prognosis, and only mitotic count strongly influenced both distant metastasis-free survival (91, 82 and 74%, P=0.014) and overall survival (97, 87 and 85%, P=0.011).”

So, according to that source, I don’t need to worry that my tubule formation score is 3 and my nuclear score is 2. I should be simply grateful that my mitosis score is 1, which gives me a better prognosis.

Breast Cancer.about.com had an explanation that made sense to my brain.

  • The “degree of tumor tubule formation” is the “percentage of cancer composed of tubular structures.”
  • The “tumor mitotic activity” is the “rate of cell division.”
  • The “nuclear grade” refers to “cell size and uniformity.”
  • They have an illustration that shows the difference between a normal cell and a cancer cell that you might like to see on this site drawn by Pat Kenny.

Back to my Nottingham Score, grade 1 is a “slow cell growth rate.” Grade 3 is a “fast cell growth rate.” I have the happy medium, if you will, of grade 2 which is an “intermediate cell growth rate.”

Okay, enough research about that. I feel like I understand my pathology report pretty well now.

Final point:

If you watch the following YouTube video called “News for the Cure™ – Types of Breast Cancer”, it appears that I have Stage 2 Breast Cancer as my lump is large; however, it has not yet spread outside my breast to the lymph nodes or to other parts of my body. At least, that is what the Diagnostic Mammogram revealed.

My husband and I went to the Health Department at 2:00 so I could sign some papers to be put on Presumptive TenCare that lasts up to 45 days. One of the next steps is to visit the Department of Human Services to fill out further paperwork that will help me extend the 45 days up to 5 years, providing I see my oncologist every 6 months and fill out more paper work and get an updated “Plan of Care” to send to them from my oncologist doctor. By the way, I had his name wrong before. My oncologist’s name is Dr. Patel. He comes very highly recommended.

My appointment with my surgeon, Dr. Patterson, also highly recommended, is on Tuesday, January 12th, at 3:15. That is when Dr. Patterson should have the rest of my pathology report. He will schedule me for a cat scan and a bone scan. This will tell what stage of cancer I have, which I think is stage 2. Those scans will reveal whether the cancer has had a chance to spread to any other parts of my body.

Then he will schedule me for surgery with a dose of radiation possibly first. He will also give me a referral to my oncologist, Dr. Patel.

I asked about chemo. Every woman is different. One woman said she gained 30 pounds as a result of chemo. My husband, who listened in on the phone call, quickly said, “More to love.” He is such a sweetie! Other husbands could take lessons from him.

She explained that I might be put on a low grade form of chemo that does not cause hair loss. This is called Tamoxifen. The way she explained it is that the estrogen in our body acts like fertilizer to cancer cells. It feeds the cancer. The chemo suppresses the estrogen. From what I read, the benefits of Tamoxifen outweighs the side effects. The nurse practitioner explained that I might actually have to take Tamoxifen for up to five years. Perhaps I misunderstood her on that score. Apparently, Tamoxifen is a tablet taken orally.

Cancer.gov states that “Tamoxifen helps prevent the original breast cancer from returning and also helps prevent the development of new cancers in the other breast. As treatment for metastatic breast cancer, the drug slows or stops the growth of cancer cells that are present in the body.”

The site does say that typically, cancer patients might need to take this tablet for five years. So I guess I heard the nurse practitioner correctly.

Well, I know this is a lot to process. I felt like I needed to gain a handle on what is happening. The research caused me brief flashes of alarm; however, I mostly feel relieved that I can now talk to my surgeon more intelligently about what is going on. I’m sure not approaching this like the stereotypical blond, am I? Smile!

I love you all! I so appreciate your love, support, and prayers. Most of all, please help me hold out the vision that in the end, I am healthy and whole, living as a breast cancer survivor aka thriver.

With so much love,
Healing Seeker aka Debbie


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