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Dr. Andrew Rynne

Family Physician

Exp 50 years

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What do these lab reports indicate?

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Dr. Deepak Sundriyal

Oncologist

Practicing since :2005

Answered : 1416 Questions

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Posted on Thu, 19 Apr 2018 in Cancer
Question: Dear Doc

Trust this gets you well. I have been diagnosed with “INVASIVE DUCTAL CARCINOMA – GRADE II” in my left breast at around 2.0 clock position. I have attached herewith all relevant reports in sequence of the developments so far.

My Doctor’s (A leading Oncologist in Pakistan) has advised Lumpectomy followed by chemotherapy & radiations. She thinks my tumor’s behavior is better than usual and it seems to be in a very initial stage and small in size. She is also optimistic that my body will respond to medications because my ER & PR are positive

On the other hand my brother (an ORTHOPEDIC SURGEON based in USA) is of the opinion that I should go for Mastectomy followed by chemotherapy & NO RADIATIONS AT ALL

I have to be admitted in the hospital tomorrow and lumpectomy is scheduled on Friday (24th Nov, 2017) afternoon

My questions for you are as follows:

What is your recommendation? Should I opt for LUMPECTOMY or MASTECTOMY based on the reports I have attached?
Is it correct that the chances of reoccurrence of my type of tumor after lumpectomy are 15%?
Is it correct that the usually my type of tumor reoccurs far more aggressively and it’s not traceable in early stages even if we keep monitoring on regular basis?
Is it correct that the chances of reoccurrence of my type of tumor in same area (behind the breast even after mastectomy) or any other area of the body are 10%?
Is it correct that the chances of reoccurrence of my type of tumor in my right breast after mastectomy are 10%?
Is it correct that in case of lumpectomy; the radiations will cause damage to my heart and lungs in the long run?
Is it correct that radiations might be the cause of reoccurrence of cancer after 5-10 years?
Is it correct that in case of mastectomy I can get breast restructuring done at a later stage (after treatment)? Actually the facility of breast structuring is not available in Pakistan and I will have to go abroad (most likely Dubai, Bangkok or Singapore) to get this done
Do you agree that there are chances to avoid chemotherapy & radiations (in case of lumpectomy) if results of Sentinel lymph node biopsy and immunohistochemical are favorable, given that the size of the primary tumor is small?

Finally my last question:

If you look at my reports from the date of initial diagnosis of a CIST in my left breast dated Oct 25, 2017 till Nov 20, 2017 (total 25 days), there is a gradual increase in size as follows:

1.     Memogram & Ultra Sound Report dated Oct 25, 2017 shows size @ 7 MM
2.     Ultra Sound (after FNA) dated Nov 03, 2017 shows size @ 11 MM
3.     CT Scan (after FNA & Trucut Biopsy) dated Nov 11, 217 shows size @ 17 MM
4.     Repeat Ultra Sound (after FNA & Trucut Biopsy) dated Nov 13, 2017 shows size @ 20 MM

I do understand that every opinion of radiologists in terms of size may vary but the sequence is showing a gradual increase in size which is a point of concern. I think that due to needle biopsy followed by Trucut Biopsy may have caused hemorrhage and swelling in the CIST and might be the reason for increase in size or is it because the tumor is spread rapidly. The size of cist has increased from 7 MM to 2 CMs in just 25 days and to me as a patient; this kind of progression is very alarming but my Doctor is not worried with the variance in the reports – Please give your opinion on this matter?

My apologies for registering so many questions but I am totally confused at this moment. I can opt for lumpectomy or mastectomy but I have very little time left to take the right decision. I request you to kindly review all my reports date-wise and advise your suggestion / answers on above asap. Your guidance will be of great help to me

Thanks
XXXX
doctor
Answered by Dr. Deepak Sundriyal 1 hour later
Brief Answer:
hello. lumpectomy and mastectomy have same results in your case

Detailed Answer:
Hello dear.

There is absolutely nothing to worry and getting confused. with these findings in your case, breast conservation surgery (bcs) and modified radical mastectomy both have similar results with sentinel node biopsy. Of course you are a young lady and breast conservation will preserve your cosmesis.
The chances of recurrences after bcs are similar to mastectomy and are around 10 percent either at local site or regional, in your case.

Your tumor is most favourable of all and it is not at all aggressive.
after lumpectomy/(bcs), radiation is must and it doesnot cause any damage to lungs or heart as radiation techniques are nowdays very sophisticated and specific.
radiation do cause secondary cancer like sarcoma after a very long time, but that is very very rare.
after mastectomy, breast reconstruction can be done anytime.
Chemotherapy can be avoided post mastectomy or bcs depending upon the results of final histopathology on tumor tissue. This is confirmed by oncotype dx test. You can discuss this with your doctor.

Thanks and regards
feel free to ask further
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Deepak Sundriyal 4 hours later
Dear Doc

Thanks for a very detailed reply. Just a few more questions for further clarity:

1. You have mentioned that:

"Chemotherapy can be avoided post mastectomy or bcs depending upon the results of final histopathology on tumor tissue"

So if I opt for BCS, and my histopathology report is favorable, I can get away with Chemotherapy but RADIATION will remain a MUST?

2. If I opt for mastectomy, then RADIATIONS are not required at all? And the chances of getting away from Chemotherapy (provided my histopathology report is favorable) are also there?

3. Although you have given equal weightage to both; BCS (Lumpectomy) & Mastectomy but I do get the impression that you are personally more in favor of BCS primarily because of the non aggressive nature of my tumor and keeping into account my age & cosmetic issues. Can you give me a suggestion based on the reports I have provided - like go for BCS or go for Mastectomy?

4. The main advantage I see in BCS is that I can avoid reconstruction of breast from another country plus an extra surgery / treatment etc related to reconstruction. Also I have learned that even in reconstruction there are chances of complications like puncturing of implants or any infection. Also I have learned that I will lose sensations on the breast and I will always remain cautious of getting injured or falling down etc (primarily because I am an exercise freak). Please comment on this point

5. Whereas if I go for Mastectomy I can definitely get away from Radiations? But I will have to go through the process of reconstruction from another country with all the associated issues

In light of above, can you give me suggestion or let's say your final take based on the evidence you have seen so far and our discussion. If you can give me a direction, it will be very helpful because tomorrow I will be admitted in the Hospital and I have tell my Doctor (Oncologist here in Pakistan) what is my final decision - She is open to both but as I mentioned earlier, her take is BCS and my brother's take is Mastectomy (also a Doctor based in USA) so I need 1 more vote either in favor of BCS or Mastectomy and I am relying on you

Sorry to have put you in the hassle. I know that your verdict would be just a suggestion and I have read the DISCLAIMER just below your last advise and I fully agree to it

Thanks
Mrs XXXX


Hi Doc

I think you missed out on this point from my initial message in your last reply:

QUOTE:

I do understand that every opinion of radiologists in terms of size may vary but the sequence is showing a gradual increase in size which is a point of concern. I think that due to needle biopsy followed by Trucut Biopsy may have caused hemorrhage and swelling in the CIST and might be the reason for increase in size or is it because the tumor is spread rapidly. The size of cist has increased from 7 MM to 2 CMs in just 25 days and to me as a patient; this kind of progression is very alarming but my Doctor is not worried with the variance in the reports – Please give your opinion on this matter?

UNQUOTE

Can you also put some light on this point while replying to my other questions in latest mail I have just sent

Sorry for the trouble

Thanks
MrsXXXX


doctor
Answered by Dr. Deepak Sundriyal 9 minutes later
Brief Answer:
Hello. Choice depends on you

Detailed Answer:
Hello dear. So radiation is must after bcs. After mastectomy , if there are no positive nodes, radiation is not required.
Chances of getting away from chemo will depend upon oncotype dx test. We can have a discussion on this after surgery as i dont want you to get more puzzled and anxious.
As i already said, results of both bcs and mastectomy are equal and the final call will be yours.
Post bcs, breast doesnot loose sensations and you will have same feel n touch. Of course, post mastectomy , a reconstructed breast wont give you same feel and XXXXXXX
You have to decide for bcs vs mastectomy. Results are same for both.
Relax and be positive.
Thanks and regards
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Deepak Sundriyal 32 minutes later
Doc...thanks - ur response is really quick

I think my last message was not delivered to you. I just need your opinion on a question I asked earlier - I think you missed out on this point. Let me quote / unquote for ready reference:

QUOTE:

If you look at my reports from the date of initial diagnosis of a CIST in my left breast dated Oct 25, 2017 till Nov 20, 2017 (total 25 days), there is a gradual increase in size as follows:



1.     Memogram & Ultra Sound Report dated Oct 25, 2017 shows size @ 7 MM

2.     Ultra Sound (after FNA) dated Nov 03, 2017 shows size @ 11 MM

3.     CT Scan (after FNA & Trucut Biopsy) dated Nov 11, 217 shows size @ 17 MM

4.     Repeat Ultra Sound (after FNA & Trucut Biopsy) dated Nov 13, 2017 shows size @ 20 MM



I do understand that every opinion of radiologists in terms of size may vary but the sequence is showing a gradual increase in size which is a point of concern. I think that due to needle biopsy followed by Trucut Biopsy may have caused hemorrhage and swelling in the CIST and might be the reason for increase in size or is it because the tumor is spread rapidly. The size of cist has increased from 7 MM to 2 CMs in just 25 days and to me as a patient; this kind of progression is very alarming but my Doctor is not worried with the variance in the reports – Please give your opinion on this matter?

UNQUOTE:

Also I need your advise on something slightly out of context. I got liposuction done on my arms, waist and stomach in May/June 2016. I have not mentioned about this to my Doctor because I usually go to see her with my sister and mother in law. Here in Pakistan liposuction and similar treatments are still considered a taboo so I avoid telling my Doctor in front of my family. Only my husband knows about the treatment. Do you suggest that I should tell my Doctor tomorrow about liposuction - its been almost 19 months now and I never had any issues with this treatment. Is it a MUST to tell her?

I hope that after this mail I wont bother you again till my post surgery reports come

Thanks and waiting for your reply
Mrs XXXX
doctor
Answered by Dr. Deepak Sundriyal 4 minutes later
Brief Answer:
Hello. Variation in size is false

Detailed Answer:
Hello again. So the ultrasound of breast is observer dependent and variation in size is thus false. Moreover a biopsy can cause hemmorrhage in breast and an apparent increase in size. Breast cancer doesnt increase in days
Liposuction has no relation with cancer. You can get it done as you like. Nothing to worry. Just relax. You can bother me anytime. No issues
Thanks and regards
Above answer was peer-reviewed by : Dr. Prasad
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