Take two

The cool kids call this procedure a MRIGCNP.

Just kidding. Although, they might, now that I think about it.

We just got done with the MRI guided core needle biopsy. It was a long one (a bunch of setup and then about an hour and a half of “MRI’ing” and “extracting”). Before the procedure Dr. Daniels (the radiologist) showed us the “areas of concern” (AOC) as seen in her previous left breast MRI. They are in the “upper inner” and “lower inner” quadrants of the breast. It was really amazing to watch him use the middle mouse button to scroll through slices of the breast. (This would be even cooler were it not for our current “situation.”) The lower area appeared to have the same “cauliflower” like shape as the DCIS in her right breast. That being said, Dr. Daniels said the right breast could be a mix of benign and malignant cells so the cauliflower doesn’t indicate malignancy. Dr. Daniels also told us that if Jul didn’t have the cancer in her right breast, they would have just monitored these AOC and not done a biopsy. He doesn’t believe it is carcinoma but would like to be safe.

Like a standard MRI, Jul has to lay on her stomach without moving for the entire time. Unlike the standard MRI, they are sticking things in her during the procedure. Jul described this entire procedure as “excruciating,” which appears to have been a well chosen word. Fortunately it wasn’t painful — just horribly uncomfortable in the “sit in one place for 3.5 hours” way. The machine was different — instead of the long tube, there are two donut-like magnets (like oversized CT machines) that create a gap to allow the doctor to access the patient during the procedure.

MRI machines make these “wah wah wah wah” sounds and then loud “bang bang bangs” constantly. They always sound like they are broken. Dr. Daniels said the “wah wah wah wah” sound was the cooling tanks which keep the main magnet at 6 degrees Kelvin (brrr…that is colder than winter). The loud “bang bang bang” noises are smaller magnets that are moving around to create a differential magnetic field. They make that noise because they are fighting against the pull of the main magnet. If anybody knows how to make a small magnet resist a huge magnet at 6 degrees Kelvin without making banging noises, please let me know.

Once Jul is all situated they start taking scans. At some point they give her contrast to highlight the AOC. Then using these scans as maps, they insert tubes into her breast. Once they are in, they run another scan to verify the tubes terminate in the AOC. Once everything is set, they fish these nanobot-motor like things down the tubes and they extract a circular area of tissue for pathology.

The samples were off to the pathology lab today and Dr. Daniels hoped we could get results by the end of the week (sigh).

Jul is now getting another MRI done as part of a research study testing new imaging software, which should take about an hour. They had lots of tests of imaging women without cancer, but none of women with cancer. It’s their lucky day, I guess. Of all the crazy tests we have had to do, Jul’s least favorite is the MRI. And now she has had four. The irony is thick, like breast tissue.

Thanks, I’ll be here all night.

After that, on to acupuncture, and then, hopefully, back to the ranch.

p.s. Can we get an open wireless network at the hospital? I had to kill a resident just to get a terminal with an internet connection. That probably won’t scale.

• Reconstructive surgery pre-op - Jan 30th 
• MRI guided left breast biopsy - Jan 31st
• Mastectomy pre-op - Feb 9th
• Lymph node injection and scan (so they can find the Lymphs during surgery) - Feb 14th
• Mastectomy - Feb 15th

Only one test (we know about) remains to be scheduled.

Bone scan is clear. Whew — big, huge, major sigh of relief.

Jul’s cancer came back hormone receptor positive. This is a good thing because it means the cancer basically feeds off a hormone like estrogen. If necessary we can starve it using a drug like tamoxifen which blocks the hormone receptors to the cells.  We didn’t get what percentage (sometimes it is accompanied by a percentage) of the cancer was hormone receptor positive.

MRI guided biopsy of the left breast is looking like Feb 2nd. They might have a cancellation on Jan 31st.

The genetics team at Stanford is going to do a genetic work up on Jul to see if she has a genetic mutation that makes her receptive to this cancer. If she does this would increase the chance it could spread to the left breast and so might change how we think about treatment.

Here is how it breaks down now.

Jul got her bone scan yesterday. This involves injecting a radioactive isotope into her blood, waiting 3-4 hours, and then scanning her with a full body X-ray machine. There are a couple different types of bone scans — the one we did is called a scintigraphy. It detects areas of increased or decreased bone metabolism. Basically the isotope (or radiotracer) is absorbed by the bone marrow at a specific rate. When it absorbs it at this standard rate it shows up as gray in the X-ray. Abnormal metabolism shows up as either dark hot spots that indicates greater tracer uptake or light cold spots that show decreased bone metabolism. Cancer in the bones interrupts the normal metabolism rate.

Go gray.

The X-ray took about 40 minutes with Jul lying on a table without moving. Once they completed this, the tech told her she needed to go check with the doctor to “see if she needed to do additional scans.” Then she was gone for over 15 minutes.

A patient who was getting scanned for a bone fracture might not notice the time pass. For a cancer patient every minute is like an hour. If they need to take more scans that is a bad sign and so the longer you wait, the more you expect them to come back and tell you they need to focus on some “areas of concern.” A cancer patient has already had this happen once — that is why they are a cancer patient.

It wouldn’t be hard to handle this differently. When I get my chest X-rays as part monitoring my cancer the tech tells me, “I’ll be right back! I need to go verify I got the right coverage. I should be gone about 15 minutes.” Then they come back in five. I know what she is doing but she doesn’t remind me and doesn’t make me wait longer than I expect.

Everybody involved in this process needs to understand the cold, relentless fear of waiting for somebody to tell you how much time you have left and what your quality of life will be during that time. I don’t ever expect this process to not suck — I just want it minimize the suck wherever possible.

We should have the results from the scan in 48 hours.

The radiologists feel they can biopsy the suspicious areas in the left breast given they have an MRI to work from. Test is yet to be scheduled.

The left breast MRI results came back with two small suspicious areas. I didn’t get the exact size.

There are two ways we can go from here. First is a core biopsy of the left breast like we did with the right. The advantage to this approach is if it turns out to be cancerous, we could take both breasts as part of the same operation. The draw back to this approach is that we aren’t sure we can hit the suspicious areas with a core biopsy given their size. The other option is to do a surgical biopsy during the mastectomy. The advantage to this approach is we can have a higher degree of confidence we are sampling the right area. The draw back to this approach is if it turns out to be cancerous, we would need an additional operation which would add to the many she will already need.

Dr. Dirbas is following up with the radiologists. If they believe they can hit the suspicious area with a core biopsy we will go that way.

Our friend Melodie is in Addis Ababa, Ethiopia right now and on Sunday she found us a goat. Actually it turns out it was a sheep but she didn’t know that until after the transaction was complete. The going rate for goat sheep sacrifice in Ethiopia is between 300 and 500 Birr. FYI.

In other news Drew Davis, dear friend and family laywer, entered the betting pool with a estimate of a 6.25 cm infected area — somewhere in between Dr. Dirbas and the oncologist. If he is right, remind me to ask him how he knows my wife’s breast so well.

Quiet day today - only the bone scan die injection at 1:30 and bone scan at 4:30.

Tippy bought us a great book on Breast Cancer that gives good insight into DCIS (thanks Tip). Surprisingly there is relatively little that is known about it given the high incident rate. Some doctors call it pre-cancer because DCIS doesn’t actually spread. “Ah,” you say, “then why are we worried?” Excellent question. It doesn’t spread, but it seems to turn into something else that does. So when they say it doesn’t spread, they are being literal. Kind of like saying Bruce Banner doesn’t actually kill anybody — the hulk does. You just never know when (or why) he turns into the hulk. That being said, it is an important point because if they find only DCIS in your breast, you can be relatively confident it was confined to the breast.

There are a couple of theories on how DCIS results in invasive cancer. One involves a weakening of the duct walls due to a hormone like estrogen, another is it works through the duct wall to spread to the tissue. In both cases you would have to assume DCIS mutates when it hits the tissue because they never find DCIS outside the duct.

As I understand it all they have done is found that women with invasive cancer often have DCIS. They haven’t actually figured out if and how it turns into invasive cancer. This would lead me to believe it is equally possible that women who are prone to DCIS also happen to be prone to invasive cancer. Meaning there is some common characteristic that makes it easy for both DCIS and invasive cancer to develop. But what the hell do I know.

Estimates on the likelihood of untreated DCIS resulting in invasive cancer vary wildly. Studies seem to have shown everything from a 15% to 65% chance that untreated DCIS will develop into invasive cancer.

DCIS treated properly seems to lower the percentage of developing invasive cancer to about the same as a women who didn’t have DCIS. “Properly” is mostly defined by margins, which represent how much distance there is between the cancer and the surrounding tissue when they remove the infected mass.

Enough boring science for today. Right now we are waiting for the results of the left breast MRI and the bone scan so we can figure out a plan. If all comes back clear we might escape with just a mastectomy and no further treatment.

I summarized the test progress on the test result page.

CT scan came back clear. This means there was no visible spreading.

We also got back the final pathology report on the breast tissue. They confirmed there was no “definitive invasive carcinoma.” This is the best news we could get at this point.

More on this later.

Uneventful MRI and CT today. Bone scan scheduled for Tuesday.