I was just diagnosed with Phyllodes Tumor of the Breast. What does this mean?

First, let me say that I do not want to interfere with your medical care and your relationship with your treating doctors. Your doctors are more familiar with the details of your case and I would be doing you a disservice to pretend otherwise. I defer to their expertise. Please make sure you follow up with your doctor.

My answer below to your question is intended to be for general informational purposes only and not medical advice.

However, generically speaking, I can provide you with a short overview of Phyllodes tumors and some of the more common considerations encountered by patients and physicians when treating these tumors and I hope that this information is helpful to you.

First, Phyllodes tumors are relatively rare. Because of this, we don’t have too many large studies that enable us to fine-tune our evidence based medicine approach. Stated another way, we just don’t have as much experience with them as we do with other tumors. However, there are still a few things that almost everyone agrees upon that should be helpful to you.

In general, Phyllodes tumors (note alternative spellings and various pronunciations are common) can be relatively difficult to diagnose. They often look just like a fibroadenoma on ultrasound and mammogram and even when a biopsy is done, it can still be hard to determine specific characteristics of the tumor under the microscope. This is in part because Phyllodes tumors exhibit a spectrum of behavior from benign to malignant.

One of the most useful characteristics to determine how the tumor is behaving (benign versus malignant) is to look at how quickly the cells are dividing. The quicker the cells are dividing (generally referred to as mitotic rate), the more aggressive the tumor and the more likely it is malignant. Because cells may divide at different rates in different areas, it is useful to examine a larger area of tissue to get a more accurate overall impression. For this reason it is useful to have as much tissue as possible for examination.

However, mitotic rate is not the whole story, there are other very specific tissue characteristics which require special tests to be done on the tissue which can give clues about the tumor’s behavior. For this reason, it is useful to have an expert pathologist familiar with Phyllodes tumors make the diagnosis. Often, even with the best of circumstances, the Phyllodes tumor can only be classified as “middle grade” or somewhere between benign and malignant.

In any event, because of all of these considerations, it is widely agreed upon that the tumor should always be removed regardless of the initial impression from biopsy (whether benign, borderline/intermediate grade, or malignant). This is done by completely removing the tumor along with some surrounding normal breast tissue to ensure removal is as complete as possible (known as wide local excision). A surgeon with experience in removing tumors from the breast should be able to successfully perform the surgery.

After the tumor is removed, all of the tissue will be examined and a final diagnosis will be made about the tumor. About 10-25% of the tumors are determined to be malignant. However, most of the time the removal of the tumor alone is curative. A small percentage of the time the tumor returns and a second surgery is needed. In general, no other therapy other than surgery is recommended to treat Phyllodes tumors. The overwhelming majority of all patients with a diagnosis of Phyllodes tumors on biopsy do remarkably well.

I hope this helps.

Ryan Polselli, MD, DABR

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Mammogram Nonsense is Keeping me up at Night -by Ryan Polselli, M.D.

Last night I read the following question on a public Q & A forum:

Why are doctors still ordering mammograms when I’ve seen it reported in several reputable sources that mammograms don’t reduce cancer risk via early detection, and may cause cancer?

The question, from a non-medical professional, I thought, was fair. I understand that there is a lot of confusion among patients and the public about screening mammograms. However, one of my colleagues, an oncologist, attempted to answer this question and actually agreed with the premise! I was floored by his answer. What nonsense! I couldn’t sleep. How could any physician hold this belief? I tossed and turned for an hour. At 3 AM I went into my office to write my own answer. Here it is…

Screening mammography is one of the biggest successes in modern medicine. Period. It is the poster child for a successful screening program. There is not an educated person in the world that can argue or would even attempt to argue that mammograms don’t save lives.

If you are a woman and you want to increase your chances for living longer, wear your seat belt, eat well, exercise, and…get your mammogram.

All major organizations in the United States and countries of the modernized world that have repeatedly analyzed the data have all come to the same conclusion and continue to recommend mammograms in order to save lives.

This includes the American Cancer Society, the United States Preventative Services Task Force, The American College of Radiology, Society of Breast Imaging, the American Congress of Obstetricians and Gynecologists, and the National Comprehensive Cancer Network, among others.

Unfortunately, to answer part of your question, for reasons that are hard for me to understand, it seems that lately harmful hysteria and disinformation that flies in the face of science and logic have been shamefully making their way into cult culture and even to a degree mainstream medicine.

With all due respect, look no further than the former answer by one of my oncology colleagues. He says, “Routine mammography has resulted in a huge increase in the number of women diagnosed with breast cancer but no corresponding decrease in mortality.” This could not be further from what the overwhelming majority of evidence demonstrates.

For example, randomized controlled trials of women invited to screening mammography (traditional screen film) from 1963 to 2000 demonstrate early detection and treatment of breast cancer have reduced the proportion of late stage breast cancer and led to a 20–30% decrease in mortality among these women.

Additionally, more recent data using more modern equipment and techniques have demonstrated even larger gains. In some age groups and demographics, this results in a near 50% decrease in mortality. This data is now well established and has been reproduced multiple times in multiple studies in several countries throughout the world including the United States, Canada, and Europe. (Broeders, et al. 2012; Lee, et al. 2010; Oeffinger et al 2015; Siu 2016).

So why is there any confusion about this subject at all?

One possibility is that the ideal frequency and timing when women should obtain mammograms is not as clear cut as their well established effectiveness. That is not because they may not be doing their job, but that at some point, the more you screen, the less the screening returns any significant results and the more that screening may begin to result in harm.

For example, it does no good to screen for breast cancer with a mammogram every day, every week, or even every month. As the author of this question rightfully points out, a small dose of radiation is given to the breast with every mammogram and it’s very unlikely that anything will change on a daily, weekly, or even monthly basis. Additionally, mammograms can sometimes result in extra biopsies which turn out to be nothing to worry about. So a few organizations have started to try and tweak the traditional yearly mammogram recommendations. However, this does not mean in any way that mammograms don’t work and don’t save lives!

The first organization to tweak the traditional recommendations was the United States Preventative Services Task Force (USPSTF). This organization is the somewhat “rogue” group that for better or worse likes to challenge the status quo in the medical world. In 2009, they changed their recommendation to state that a woman should have a mammogram every other year beginning at age 50 instead of every year beginning at age 40.

Their recommendation was based largely on the fact that they didn’t feel the extra cancers that would be detected or the advantage of earlier detection with an annual regimen were worth the extra biopsies that would be needed and the anxiety that they would produce. It was not based on the number of lives saved nor focused on radiation to the breast. In fact, their data acknowledged that more women would die from their recommendations, but that the number was acceptably small and not worth what they consider harm largely in the form of anxiety from extra biopsies.

You can now understand why this recommendation sent shockwaves through the medical community and became (and remains) one of the most hotly debated decisions in modern medicine. If you are interested in more detail about this decision, read an article I wrote here:

What Really was Said at the Water Cooler in 2009: USPSTF Breast Cancer Screening Recommendations and Current Physician Practice Patterns.

One final note in conclusion to try to completely answer the question. It is true that mammograms do give a dose of radiation to the breast. The best data I have available to put this into perspective in terms of risk benefit for a patient is as follows:

The potential risk from radiation to the breast is the risk of inducing a fatal breast cancer. For a woman at the age of 65 this risk (from a single mammogram) is estimated to be 0.3 in 100,000 (Hendrick 2010).

However, the benefit is the detection and treatment of cancer before it is clinically apparent. In this age group the likelihood of this is about 1 in 500. Furthermore, the chance that this detected cancer would be fatal without a mammogram is about 1 in 4.

In short, if you do the math, the benefit to risk ratio for a mammogram in this age group is somewhere between 90:1 and 180:1.

As you can see, like I said in the beginning of this article, if you are a woman and you want to live longer, do not bet against odds like this and get your mammogram. I hope this helps clarify some of the mammogram nonsense floating around out there.

Ryan Polselli, M.D., Diplomate of the American Board of Radiology, Fellowship Trained Breast Imaging Radiologist

Please note that this blog is intended for general informational purposes only and is not intended to be medical advice.

“Is ABVS Ultrasound Better at Detecting Abnormal Tissues in Breasts than Conventional Ultrasound? I Heard that, in one Doctor’s Opinion, ABVS Ultrasound has High Radiation. Is it True?” –Answer by Ryan Polselli

First, the doctor that told you about the radiation with ultrasound is dead wrong. Automated whole breast ultrasound (ABUS) is also referred to as automated breast volume scanner (ABVS). They are essentially the same thing but different manufacturers of the equipment like to distinguish their products and techniques. Both are forms of ultrasound and have no ionizing radiation at all. Zero. Period.

Automated Breast Ultrasound System

Now that that’s out of the way, ultrasound of the breast has recently been shown to be useful in detecting some cancers that mammography may not show.

Note, please keep in mind there are many cancers that will definitely not show up on breast ultrasound and therefore screening for breast cancer with ultrasound alone should never be done because cancers will definitely be missed.

While ultrasound can be useful for screening for breast cancer, one problem with the traditional method (ultrasound tech or doctor holds probe in hand and moves it around to look at the breast tissue) is that it can take a long time. Many complete and thorough exams can take 30 minutes or even an hour depending on the size of the breast, complexity of breast tissue, and experience of the ultrasound technologist or doctor.

Another problem with the traditional ultrasound method is that the quality of the exam completely depends on the ability of the ultrasound technologist or doctor. Some people are good at it, some are not. I have seen large cancers completely missed after 30 minutes of scanning only to be found 30 seconds later by a different technologist or physician coming behind to re-scan the patient.

ABUS/ABVS makes the traditional ultrasound more reliable and shorter. While it cannot replace (and in many aspects will never be as good as the expert performing the traditional ultrasound), it makes using ultrasound to screen for breast cancer more realistically feasible in today’s world.

So should everyone be screened with automated breast ultrasound AND mammography? The answer as of now (according to breast practice in line with what the research has shown) is ‘NO’. While it is true that more cancer will be detected, the one problem with screening breast ultrasound is that it picks up many abnormal appearing areas in the breast that do not turn out to be breast cancer. In other words, it’s very likely that ultrasound will find something in the breast that needs to be biopsied because of the way it looks, but it turns out NOT to be breast cancer.

As of now, the benefit of the extra cancer detection from screening with ultrasound only seems to outweigh the risks of biopsy for patients that have a higher risk for breast cancer such as strong family history or dense breast tissue.

Anyone concerned of the above should talk with their primary care doctor.

Ryan Polselli, MD, Diplomate of the American Board of Radiology, Fellowship Trained Breast Imaging Radiologist.

Please note, this is intended for general informational purposes only and is not intended to be medical advice.

Breast Implants and Anaplastic Large Cell Lymphoma (ALCL): Should I be Concerned? —by Ryan Polselli

There are an increasing number of reports in the media lately about a new relationship between breast implants and an extremely rare form of cancer showing up in the breasts. Notice that I did not say breast cancer. That is because although this cancer is found in the breast, it does not appear to arise from breast tissue.

ALCL surrounding the breast implant in the right breast

This cancer, known as Anaplastic Large Cell Lymphoma and commonly referred to as ALCL, started showing up in cases of women that had persistent fluid accumulation within the fibrous capsule that the body forms when the implant is placed within the breast. Although fluid collections around the implant sometimes occur when the implant is initially placed, this fluid was showing up years after placement and seemed to persist despite typical treatment. As a result, some of these women underwent a second surgery in an attempt to correct the problem. When the fluid was sent for analysis, the cancerous cells were detected.

Reports of this phenomena started showing up in the literature until there were enough eyebrows raised to launch an official investigation by the FDA. Until recently, ALCL was known to be an extremely rare cancer that could involve the breast, but was better known for showing up in other areas of the body. Although it was known to occur in approximately 1 in 500,000 women each year, it only showed up in the breast 3 times for every 100 million women each year. The compilation of all the cases reported however, showed that it had shown up in the breasts of women with implants approximately 60 times worldwide when the total number of implants was estimated between 5 and 10 million.

So what has been concluded from these 60 cases worldwide? Only 34 of these cases had data reported that was deemed reliable enough to be included in the FDA’s study of cases from 1997 though 2010. From a statistical standpoint, there was not enough data to reliably determine any defining characteristics. ALCL occured in both implants with silicone and saline that had been placed for the purpose of reconstruction and augmentation.

There are some reports in the media stating that it is likely that the cancer is being caused by implants that are textured. This is because of the 4 cases of cancer in which the implant shell texture was known, they all happened to be textured. However, this could still be coincidence. We still don’t know what type of shell was involved in the remaining 30 cases.

Because more information is still needed, the FDA has formed a registry in association with the Society of Plastic Surgery to record all cases of ALCL. The FDA is requesting all confirmed cases of ALCL in women with breast implants to be reported to the FDA. The FDA has agreed to keep the reporter and patient’s identity confidential.

So what does all this mean for the average woman with breast implants. In short, don’t be alarmed. The incidence is so low and still so little definite information is known at this point that there is no need to run to your local surgeon to have breast implants removed. In fact, it is the official recommendation of the FDA at this point that implants should not be removed unless there is medical reason. The FDA continues to stand by the overall safety of breast implants when used appropriately.

Ryan Polselli, MD, Diplomate of the American Board of Radiology, Fellowship Trained Breast Imaging Radiologist

Note, this article is for general informational purposes only and is not intended to be medical advice

What is Breast Tomosynthesis and 3D Mammography?

Breast Tomosynthesis is better known by most patients and physicians as 3D mammography. However, the use of the term “3D” is a bit misleading. There are no 3D glasses to wear as one would typically expect when viewing a 3D image or movie and nothing “pops” out of the screen in the traditional “stereoscopic” sense.* The images actually appear as “flat” 2D images but are taken at multiple angles relative to the breast and then synthesized to appear as numerous thin traditional 2D images of the breast. This enables the radiologist to look at a single picture for essentially every millimeter of thickness through the breast. Depending on how thick the breast is when compressed, there can be 70 or more images for each view of each breast. In total, there can be 300 or more images created for each mammogram. The term 3D was initially introduced for the purpose of marketing directly to the consumer and to a lesser extent the medical community, but has since become so entrenched in our vocabulary that it’s here to stay.

2D mammogram and 3D mammogram from same patient. The 3D mammogram on the left shows the breast cancer more clearly.

A useful way to understand the concept is to imagine superimposing all the individual tomosynthesis images.  The resulting image would be very similar to the traditional 2D digital mammogram that has been the mainstream of mammographic screening for the last 10 years or so. The advantage of separating the images with tomosynthesis is that it allows the breast imaging radiologist to “see through” the normal breast tissue which can traditionally “overlap.” The image above is a good example. This traditional “overlap” causes 2 main problems. It can hide underlying cancer and it can occasionally overlap in such a way to look suspicious for cancer when there is actually no cancer present. These two problems with the traditional 2D mammogram result in decreased cancer detection rates and more patient recalls for additional imaging to look for cancer that is not there. In other words, 3D mammograms (breast tomosynthesis) detect more breast cancers and results in less false alarms.

Numerous scientific studies have now demonstrated the benefits of 3D mammogram. Among them, a study published in the Journal of the American Medical Association (JAMA) in 2012 involving nearly half a million women demonstrated a significant increase in the breast cancer detection rate and the simultaneous decrease in the recall rate with breast tomosynthesis when compared to standard 2-D digital mammography.

In January of 2015, Medicare was the first insurer to begin reimbursing for breast tomosynthesis. More recently, in August of 2016, Cigna, inspired by the mammogram recommendations of the National Comprehensive Cancer Network (NCCN), became the first private insurer to begin reimbursing for breast tomosynthsis.  More recently, as of April 2017, Anthem and UnitedHealthcare have also reported that they will reimburse for 3D mammogram. Largely as a result of recent studies documenting cost saving and increased breast cancer detection rates, several states including New York, Texas, New Jersey, New Hampshire, and Maryland have introduced bills seeking mandated insurance reimbursement for patients seeking to undergo breast tomosynthesis in their states.  In the future, as the technology becomes more widespread, there will likely be an increasingly larger network of insurance companies that reimburse for breast tomosynthesis.

From the patient perspective, there is nothing noticeably different from having a 3D mammogram when compared with the 2D mammogram other than the “arm” which takes the mammographic “picture” will rotate slightly when obtaining the exposure. Unfortunately compression is still required and the experience is still uncomfortable. Patients that are pre-menopausal can minimize any discomfort by obtaining a mammogram approximately 1 week after a period or if medically appropriate, taking an anti-inflammatory before the procedure.

Ryan Polselli, M.D., Diplomate of the American Board of Radiology, Breast Imaging Radiologist

Please note, this is for informational purposes only and is not intended to be medical advice.

*Note, Fujifilm does market a traditional stereoscopic 3-D viewer, but the technology has not yet been adopted into mainstream clinical practice.

What Every Woman Needs to Know about Breast Thermography

Fluoridation of water exists to mask bad dental care to the poor. Vaccinations cause autism but the proof has been suppressed by a massive pharmaceutical company cover-up. HIV is an artifical disease created by the CIA. Condensation trails from aircraft represent the emission of biological and chemical agents into the atmosphere.

If you believe in any of the above or similar conspiracy theories, this article is not for you. However, if you believe in the scientific method and that properly applied scientific knowledge can improve health and prolong life, stick around.

 

There is an increasingly popular trend in the field of breast cancer screening. Many patients are turning to Thermography as an alternative to traditional mammography. Thermography is an older technology that uses a special camera to take infrared pictures of the breast looking for relative hotspots which are supposed to correlate with breast cancer. There is no ionizing radiation involved and it’s painless.

The theory being used to support it’s effectiveness is that tumors have increased metabolic activity and vascular recruitment which produces heat. This heat can then supposedly be detected in the form of a visual hotspot. While the gross concept is generally sound and it is true that some tumors produce more detectable heat than the surrounding tissues, many don’t.

But what do the scientific studies show? A complete review of the scientific literature demonstrates that Thermography does not reliably detect breast cancer or prolong life. In essence, Thermography is no more effective at detecting the important forms of breast cancer than throwing darts in the dark. The lack of effectiveness is likely due to the fact that breasts have a natural variation in background heat levels which mask or minimize any potential detectable heat difference between breast cancers, espeically when the cancer is small or slow growing.

So for those women wishing to improve chances of survival for a disease that shows up in 1 in 8 women, stick with traditional mammography and ignore the anecdotal stories of Thermographic success which can be found throughout the internet…along with the stories of chemtrails and vaccination cover-ups.

Note, this is post IS intended to be medical advice.

Ryan Polselli, M.D.

Diplomate of the American Board of Radiology

Fellowship Trained Breast Imager

Doctors’ Orders Differ from Mammogram Guidelines

Study finds that most still recommend the breast cancer screen for women in their early 40s

Sourced through Scoop.it from: www.webmd.com

There are numerous expert organizations out there such as the ACR, SBI, ACOG, and NCCN that continue to recommend annual screening beginning at age 40. Even the ACS that supports annual screening beginning at age 40 OR 45. Only 1 organization, the USPSTF, recommends biannual screening beginning at age 50. The USPSTF analysis on which their recommendation was made admits more women will die from breast cancer with their recommendation. Why wouldn’t doctors continue to recommend screening beginning at age 40?