Friday, December 5, 2014
The green on this photo is the lymph node system - they help with infection fighting. It was described to me as a "string of pearls" that was somewhat
draped over the breast area. At one point in early treatment, ink was injected into the nipple area. This ink travelled to the "gate keeper" lymph node - the first lymph node that anything leaving the breast comes in contact with (remember the string of pearls). The ink that was injected pointed out the gate keeper lymph nodes and they were then surgically removed and tested for cancer. (in my case, negative)
If you look on the actual breast, there are ducts that lead from the milk-producing glands to the nipple (for baby). Ductal carcinoma is formed in the ducts. Lobular carcinoma is formed in the milk-glands. Invasive carcinoma means that it has grown into the surrounding tissue, and noninvasive (usually benign) is more of a contained type of cyst. So you get a diagnosis of Invasive ductal carcinoma: it means that it started in the duct, and is now grown into the surrounding tissue. If you have lobular carcinoma, that is when the cancer has formed in the milk-glands (those big sac looking things on the picture).
Sometimes women have two or more tumors in a breast. If it is unifocal, that means there is only one tumor. If it is multifocal, that means there are two or more tumors that have formed because they broke away from the original tumor. They are usually close together then. Sometimes there are two unrelated tumors that formed on their own and one did not originate from the other. That is called multicentric. This is what I had. I had a tumor that was invasive ductal, 3cm+ that was the originally found tumor, picked up on a mammogram. Later it was found that I also had an invasive lobular tumor, 1-cm in size, missed by the mammogram, but found only through a breast MRI. The first and larger tumor (ductal) was like an acorn under my skin. I could feel it and wiggle it around. It was located half-way between nipple and armpit over on the upper side of my breast. The lobular tumor was on the underneath side close to the nipple and close to the surface of my skin.
When a surgeon is to surgically remove a tumor, either through a mastectomy or lumpectomy, there is a suggested one-centimeter margin to be considered between unhealthy and healthy cells. That is to ensure that when cancer tumor is taken out, none is accidentally left behind to keep growing. For me, the larger ductal tumor was found to be really close to the chest wall, or muscles, and is why I had to have chemo treatment prior to surgery. The hope was to shrink the tumor away from the muscle to produce a larger margin before surgically removing it. The smaller lobular tumor was close to the nipple/skin. Although I insisted for the surgeon to keep my body in tact as much as possible, which he agreed to, three days following my surgery (bilateral, or double, mastectomy) my skin died. This created a need for an emergency surgery to remove the dying skin which was turning purple. The reason it was dying was because when the lobular tumor was removed, the one-centimeter margin for the surgeon to successfully remove the tumor came too close to the skin's surface. Ultimately there was not enough tissue left behind for the skin to survive, so it died.
Cancer can move from the breast via the lymph nodes pretty easily. After it has, there is a bigger fight to survive. It can also move through the surrounding tissue, like the bones in the rib-cage or the muscles of the chest wall, or even the blood stream can carry little cancer cells and they end up growing elsewhere in the body. For example if it travels to the skin, that breast cancer original cancer on the skin is diagnosed as untreatable, whereas a skin cancer with origins of an actual skin cancer is treatable. Once it is in other parts of the body, there is a lower survival rate.
The cancer itself is graded. It is done with what is called a Nottingham Score which is comprised of three parts - all separate from each other and one does not affect the other. These three parts are tubule, nuclear, mitotic
- each getting three possible points. So when the cancer is rated, there is a possible score of 3 (one point each) or a score of 9 (each part having 3-pts each). Having a score of 3 is good, and having a score of 9 is bad. My Nottingham Score was 7/9, tubule 3, nuclear 3, mitotic 1, moderately differentiated.
The tubule score is determined by examining the cancer cells and how they nest together - if they are forming clusters around a tube like opening, typical of what normal breast cells do (forming ducts, etc) then they get a score of 1. If the tumor cells are forming nests of solid cells without an open, tube-like center, then they are performing unlike the normal breast cells would. Those will get a score of 3. It is showing that these cells are not behaving like they are supposed to, and have a mind of their own. This is a measurement of how different the cancer cell is behaving from its original cell that it mutated from.
The nuclear score is determined by looking at the tumor cells' nuclei. In a score of 1, the nuclei are all dark black uniformed in size and round shape and are patterned in somewhat of rows of cells (the nuclei is the center of the cell). In a score of 3, being yuk, the nuclei are varied in color from black to grey, they have holes in them, they have no pattern because the cells that surround them are also messed up. They have various shapes and are obvious cells turned into little monsters. This is a measurement of how ugly the cancer is.
Then the mitotic score is based on mitosis rate, which is the rate at which a cell is being split apart. If this gets a score of 1, the rate is like 10 splits and the score of 3 is 20 splits of mitosis in cancer cells. This is a measurement of the rate of growth.
All of these are taken into consideration when determining the cell differentiation grade. Grade-I is well differentiated, grade-II is moderate, grade-III is poor, grade-IV is undifferentiated (which means basically that the cancer has its own life now).
When combining the grade of cell differentiation (which means how different is the cell from its original cell it mutated from and how tough it is) with the cancer "stage" it determines a cancer patient survival rate.
Basically, as far as my research project on differences of Black women's health disparity in breast cancer survival rate - a subtype called triple negative (called so because it is unresponsive to three hormone treatments - example I am estrogen dominant as is my cancer so I take estrogen inhibitors now for another 5-yrs). This subtype has a Grade of poorly differentiated or undifferentiated cells, and the mitosis rate is rapid. The tumor is usually detected then after it is large and has already spread to the lymph nodes. The chances of survival are not good due to those biological facts. When it is combined with the disparities in healthcare access, the lower survival rate is compounded by the lack of potential for early detection and access to aggressive treatment. Also, the triple negative subtype attacks younger women who are not expecting to be diagnosed with breast cancer - also complicating an early detection. I recommend preventative measures such as awareness and yearly mammograms performed on young women. (even though an MRI is far better at detection - obviously my second tumor was not even detected in the mammogram at 1-cm in size).
It is not always an older woman health issue. I was 43, diagnosed with ductal cancer avg age of 50+, and lobular avg age of 60+. Those averages tend to lull women into a false sense of assuredness at a younger age.
Most important, don't ever assume the doctor is going to explain any of this to you as a patient because google is how I figured out what was happening to me most of the time. For example, I was sanitized, ready for surgery in a few moments, handed a consent form for silicone to be put into my body despite the risks. Right at the last minute before my double mastectomy. I said well isn't that supposed to be bad for me? Be proactive with your health