Case Number 7. Previous Lobullar Carcinoma. "Earlier Detection" , SyneIRgy" , "TABB"

 Case Number 7 . 


Female patient , Medical Dr: General Practicioner.  48 years old , with  familiar history in one aunt for breast cancer , 2 years previously  (2007)  during self exploration of an irregular right sided nodule she  attended to her physician  and after a difficult and irregular diagnosis algorithm  and a delay of 4 months , we decided to perform a biopsy :


 Invasive Lobullar Breast Carcinoma
 Negative for HER 2 neu and Hormone Receptors


Stage IIB :  T2N1M0 , she underwent a Radical Mastectomy , with a lesion of 4 cm and 2 positive lymph nodes and after wards standard adjuvant treatment. 


2009 after 2 years in control , conventional image studies were performed  :

Remaining Breast Mammogram  Lateral Oblique View  : dense breast tissue in her inferior quadrants  , superior isolated density with a "linear" aspect. 

 Cefalo Caudal view : persistance of the density in th upper and now external quadrant  . And internally an ovoidal  density

Close up for the superior density. No calcifications were seen. 

Magnification  of the upper and external density  , 

compatible with a linear " scar "image no 

calcifications were delineated either. .

Magnification of the internal lesion , opaque and ovoidal  

Ultrasound definition of the latter.  

Final Radiological Report  . 

BIRADS IV because of the presence of the INTERNAL LESION
Density towards the Spence tail of the breast
 was mentioned , yet specifically with out the 
need for a Biopsy. 

Digital Infrared Analysis as a complementary procedure : 

Evidence for an isolated Hiperthermia , that persists even after the cold sitmuli in the functional part of the study in the upper outer quadrant of the remaining breast (left) that is coincidental with the density defined in mammogram .


Suspicious by this method  with and IR Score of 125 , Peripheral Tissue delta between basal and functional studies of  1.3 degrees (obviously there is no  comparison with the contralateral breast )   

Close up for the IR  IMAGE , superior arrow corresponds to my radiological interesting area  and the reported by radiology  internal nodule (palpable) "invisible" or absent by this means. 








Which translates :  


  Suspicion for the upper lesion : Higher metabolic generation , vascular density , vasodilation , inflammation or infection . 


And  in the internal :  low heat or low  infrared radiation generation : low metabolic index  : low vascular density  , no inflammation or infection.

Having and informed consent ( patient is also a Medical Doctor)  we decided to perform both biopsies  . 


In the upper outer quadrant the IR area was delineated , lumpectomy 5 cm width was performed  down to the pectoralis major fascia . For it to be sure that no breast tissue was left behind.  


"Thermographically Assisted Breast Biopsy : TABB" you can google :" Biopsia de mama asistida por termografía

And complete biopsy of the internal nodule.



Macroscopically , the initial tissue of the lumpectomy was not revealing , yet the inferior was compatible  macroscopically and microscopically  with a benign breast fybroma.

Microscopical Images for the UPPER LUMPECTOMY  SPECIMEN: 

Definitive PAthological Report:

Atypical Lobullar Hyperplasia with , microcalcifications. Some other expert pathologist diagnosed it even as a lobullar carcinoma insitu. 

Comment: 

• Lobullar Carcinoma is a neoplastic entity of difficult diagnosis , even with the most recent or advanced current image procedures. Its incidence is around 10% or less of the total number of cases.
• So diagnostic mistakes are common  , even clinical palpable lesions are hard to define  with limits and consistency similar to an irregular "cushion"
• Also it has a multiple lesion behaviour , in foci , centers or even bilaterally.
• Hence metachronic lesiones are probable and common.
• Atypical Lobullar Hyperplasia could progress  as high as 30% of the cases with an invasive form of the disease
• Definitive treatment depends of common agreement and consensus with the patient and with the available resources , some recommend even PROPHYLACTIC  MASTECTOMY.

In this specific case  , she finally decided to have a Prophylactic treatment  so : Simple left mastectomy was performed and she started breast reconstruction.


By now she is well after 5 years of initial diagnosis and 2 years after completing breast reconstruction.  

Hypothesis:

Some Breast IR "promotors and supporters " sustain that Breast Thermography can detect lesions 8 to 10 years before Mammogram 

In my own point of view I believe this declaration is not believable and unrealistic and should be rejected by  Our scientific community (actually it is) . 


So we assume ,consider and agree that  this statement is  false , doubtful  and even dangerous . 

"Yet not all of it is totally  incorrect ".EMC

Otherwise  , specific scenario exists :

•  in high risk patients , 
• with previous history of malignant lesions of difficult diagnostic and clinical behaviour  ,
•  with doubt to recommend a  biopsy in the standard image studies 8mammogram and USG ) , 
• Located in  most frequent site (statistically)for breast cancer : Upper External Quadrant. 

And coincidental between IR findings and mammographic ones: 

" DIGITAL INFRARED ANALYSIS OF THE BREAST IN EXPERT AND CERTIFIED HANDS, COULD HELP IN A SYNERGISTICAL WAY WITH THE CURRENT IMAGE PROCEDURES FOR THEM TO DETECT  EVEN  :

PREINVASIVE LESIONS" 

 EMC.

This specific case can only be seen by an experte in breast pathology , either an oncologist , breast surgeon o radiology trained a breast image expert.

So in this particular NICH of the breast cancer population  IR could  help  and  sustain therapeutical or eben prophylactical decisions

Finally : 

Mammography still is and will be the CORNER STONE of breast cancer detection through good quality screening program .


Yet :  Initial age of Screening  and it´s frequency is controversial even between experts  , it depends on race , cultural , economical and personal factors . 


It is also related to the corresponding  Breast Cancer Statistics for a given population , 


Human resources and quality of the available equipment , technique are also important  and finally the personal interpretation experience  is a decisive factor for it to be consistent-

Regretfuly , political and some enteprise interests are commonly involved. At least that is what I feel and find it not so hard to believe.


So:

"Mammogram :  Is a very complex medical diagnostic procedure."

Breast Thermography is a reproductible method , with objective values that could help synergistically  the available diagnostic armamentarium . 


Should be thoroughly re-studied  by Breast and Oncology Experts in  controlled , prospective protocols  and  preferably in mulcenter coordination. 

"Sine(IR)gy "EMC. 
"TABB ( Thermographically Assisted Breast Biopsy)

Case Number # 6. Young Patient High Risk Dense Tissue. Enhancing Breast Physical Exam

Case 6: 37 year old female , with family history 2 cousins and an aunt for breast cancer.

Three previous pregnancies , age of first birth at 30 , negative breastfeeding.

Contraception use for 1 year .

Asymptomatic until she claims discovering on self breast examination during shower a palpable nodule in the right upper quadrant.

At Physical Examination , a palpable , irregular , gritty lesion is detected in the right breast.

Axillary lumph node (1 ) palpable suspicious for malignancy.

After conventional studies (mammogram and ultrasound) she was sent to my office.

Mammogram:

Cefalo Caudal View : From this particular view it is impossible to define the clinicallly suspicious lesion.

CLOSE UP.

Medio Lateral Oblique View : Density assymetry in the upper right region close to the skin , without microcalcifications and undetermined axillary lymph nodes.

CLOSE UP, UNDETERMINED NOT WELL DEFINED DENSE LESION

.

Ultrasound definition : a 2.59 cm lesion , taller in it's larger dimension , irregular and solid suspicious for breast carcinoma classified as BIRADS IVc.

"Enough evidence to suspect malignancy and recommend immediate biopsy ".

Complemet Digital Infrared Analysis and findings :

CCan score of 173 for right breast .

With two functional persistent hyperthermias in the upper outer quadrant of the right breast , with an average of 32.7 in the interest area

Thermal summit of 33.6,

DELTA to surrounding tissue of 1.7 and 1.4 to the contralateral breast location

IT CAN BE ASSUMED EVEN BEFORE BIOPSY THAT THIS LESION CORRESPONDS TO A :

HIGH GRADE MALIGNANT LESION .

Frontal Basal Study View. Evident assymetry is observed at the Outer Upper Quadrant of the Right Breast , with augmented vascular network at this site.

Thermal or infrared SUMMIT DEFINED using isothermal standard option at software analysis.

Objective analysis of the interest area with results given in centigrades.

PINPOINT sign : Digital Infrared Analysis in this patient could easily direct the exact location of the palpable lesion.

Quadrantectomy and radical axillary dissection.

Close up : a gritty , white , irrgular 2.5 lesion is observed with negative margins .

FINAL PATHOLOGICAL REPORT:

- POORLY DIFFERENTIATED INVASIVE DUCTAL CARCINOMA , WITH SOME MEDULLARY CHARACTERISTICS.

- SIZE: 2.5.x2.2x2CM

- GRADE III IN MODIFIED SBR.

- WITH HIGH GRADE INVASIVE DUCTAL CARCINOMA I , SOLID TYPE WITH DUCTAL CARCINOMA IN SITU APROXIMATELY IN 20% OF THE NEOPLASM.

- WITH VASCULAR AND LYMPHATIC INVASION.

- NO NECROSIS .

- SKIN WITHOUT NEOPLASTIC CELLS.

- SOME FIBROCYSTIC CHANGES.

AXILLARY LYMPH NODES :

- 19 OUT OF 19 LYMPH NODES , NEGATIVE FOR NEOPLASTIC CELLS , WITH FOLLICULAR HYPERPLASIA ONLY .

PENDING IMMUNOHYSTOCHEMICAL RESULTS.

Comment:

40 years old or less patients and probably younger than 50 (depending on race and populations) , are condemned to FAILED early detection screening results based on mammogram because of physiologic DENSE TISSUE at this age , hence most of them will seek medical attention only after the lesion is clearly palpable either by self examination or by a trained health professional.

Even if the patient has a personal or familiar high risk background , this scenario usually repeats.

So current recommendations include earlier conventional studies ( 10 years or more earlier than the age for the Breast Cancer Relative (sister , mother , grandmother and second line ones , in this case cousins and aunt) .

HYPOTHESIS : IF DIGITAL INFRARED ANALYSIS OF THE BREAST DEPENDS ON METABOLIC , SIZE , AND PROBABLE DEPTH LOCATION OF THE NEOPLASTIC LESION .

AN ASSYMETRY SUCH AS THE ONE THIS CASE DEMONSTRATES COULD PROBABLE DETECT HIGH GRADE LESION AROUND 2 CM OR LESS : T1

YOUNG HIGH RISK PATIENTS YOUNGER THAN 40 (OR EVEN 50) COULD BE APPROACHED IN A MULTI-IMAGE MODALITY ( xRAY , ULTRASOUND AND DIRA).

DIRA COULD BE SPECIFICALLY RECOMMENDED IN THIS PATIENTS AS AN INTERVAL STUDY EVERY 6 MONTHS .

ANY EVIDENT INFRARED CHANGE COULD PROMPT FURTHER CONVENTIONAL STUDIES.

interval-hr-ir (High Risk -infrared)

AS SUCH , LESION COULD BE DETECTED NEAR A 1-2 CM IN SIZE , POSSIBLY HIGH GRADE

AND COULD BENEFIT THIS SPECIFIC POPULATION NICHE AND AT THE SAME TIME :

"ENHANCE BREAST EXAMINATION BY TRAINED HEALTH PERSONNEL."

Case Number #5. BIRADS III , metabolic implications

Caso Número 5.

64 year old female , withou any personal or familiar history or risk for breast cancer.

Self examination revealed suddenly a nodule in the inner quiadrants of the right breast , otherwise asymptomatic.

She attended to her Gynecologist and sent to perform standard radiological studies : Mammogram and Ultrasound:

Cranio Caudal View : Density assymetry , an easily identified nodule in the inner quadrants .

Medio Lateral Oblique View: Inner lower nodule defined as well . Axillary lymph nodes were classified as benign or inflammatory ones.

Close up : no architectural distorsion or microcalcifications were seen.

Ultrasound image : where the nodule revealed a "solid" component , no acoustic shadow or liquid nature . Abscense of microcalcifications.

At Doppler : with a little vascular or peripheric vessels demonstrated.

Final BIRADS diagnosis was categorized as III , thus :

• Leaving biopsy decision to clinical judgement or short surveillance period 3 to 6 months .

DIRA Performed as a complementary study :

CCan Score : 173 for the right breast and only 39 for the left.

Focused vascular span from 22. 3 to 37.8 celsius degrees. (Range where vsacular components are well defined) 37 degrees or more reveal indirectly a augmented metabolic component.

Therma Summit of 33.4 degrees that is coincident qith the clinically palpable nodule.

Surroounding Tissue Delta (DTC) of 1.6 and contralateral of 1.3.

GAP between basal and "functional" (cold challenge) studies of 0.9

Right Axilla considered negative in comparison with left.

Less than 25% of visually vasculature.

The infrared image of the basal frontal study reveals the "sulcus irregularity " ( almost a dentate line ) , and a single Hyperthermia in the Inner Quadrants (1-2hr Line B9).Coincidental of the former standard image studies.

Digital manipulation of the image improves vascular components of the original image.

Surgical specimen of the inner Quadrantectomy , tumor seems "fleshy" in nature and quite different from a fybroid appearance .

Hematoxiline and eosine , revealed a:

• Infiltrating Lobullar Carcinoma , with
• Signet Ring Cells

Immunohistochemistry:

Estrogen and Progesteron Receptors were NEGATIVE .

Her2 neu +++.

Ki 67 positive in 60%

Negative axillary lymph nodes by Sentinel Lymph Node Dissection.

To this day patient is well and currently under adjuvant systemic therapy .

Later on she will receive External Beam Irradiation.

Comment:

Breast Cancer is an heterogeneous disease with and some times INDIVIDUAL:

Clinical , Radiological , Pathological ,Immunohistochemical and almost molecular

characteristics are present.

DIRA , could help the Clinician o decide whether or not a biopsy should be performed.

And although some might classify the former lesion as a BIRADS IV one , the truth is that the threshold betweet BIRADS III and BIRADS IV depends on:

Radiologist experience and Diagnostic accuracy , but most important it could also rely on interobserver examination or "mood" after 40 or 50 read mammograms.

So:

One radiologist could diagnose it as a BIRADS III

Another one could give it a BIRADS IVa

Or even a "tired" radiologist or an unexperienced one could give these image as a BIRADS II.

" TO PERFORM OR NOT A BIOPSY SHOULD INCLUDE ALL THE INFORMATION THAT COULD BE SCIENTIFICALLY ASSESSED BEFORE IT IS ACTUALLY DONE. "

By itself DIRA , translates a higher metabolic rate in the right side , oriented to the inner quadrantes so its recommendation as an screening procedure seems possible yet quite complicated.

Possible but complicated. So detection relies on mammography , but SYNERGY SEEMS POSSIBLE.

Yet the DIRA results : score of 173 "speaks" of a high grade tumour : Signet Ring cells .

And probably can be related to the morphological Immunohistocemical characteristics

" Incorporating The INFRARED LANGUAGE to Mastology , Oncology and Breast Cancer is a MULTIDISCIPLINARY task ." EMC

"I strongly believe it should be reintroduced , reexplored and reserved only to breast and oncological specialists." EMC

Case Number # 4. T1 easily detected

Case Number 4 .

Female 55 year of age , no family history for breast cancer .Asymptomatic Nodule detected during Gynecologic physical examination .

Conventional imaging studies were realized : Mammogram and Ultrasound.

Parenchymal Density assimetry in the Rigth Upper Quadrant of the Breast.

With architectural distorsion but no microcalcifications

and inflammatory Axillary Lymph Nodes.

Ultrasound . 1.57 irregular solid lesion , characteristically taller than its width measure.

Ultrasound : 1.57 cm irregular solid lesion characteristically taller than its graetest width measure.

Standard BIRADS diagnosis : V equivalent to 95% chance for breast cancer.

Digital Infrared Analyisis of the same patiente in its frontal view :

Rigth Breast IR assimetry : with locally augmented thermovascular network localized to the outer and upper. After the cold challenge or simuli : With a Delta Difference to surrounding tissue and to the contralateral region of 1.0 centigrades .

Termal summit of 34.8 centigrades , which is coincidental for the clinically suspicious lesion or nodule.

Close Up , local vesselss are delineated , otherwise "invisible" to the naked eye.

DIRA Score (CCan) of 103

Suspicious for malignancy because of the alternate variables (+ -)

Associated with standard diagnosis methods : Probably a low grade breast carcinoma with negative axillary lumph nodes .

Final Pathological Report :

Invasive Ductal Carcinoma Moderatley Differenciated .

Pacient was initially treated with : Quadrantectomy and Selective Sentinel Lymph Node DIssection .

1. Sentinel Lymph Nodes were Negative.
2. Negative Her2 neu
3. Positive Estrogen Receptors

To this date patient is in follow up after 1.9 year after treatment.

"Digital Infrared analysis of the Breast as a complementary or adjunctive study : offered data regarding biological behaviour of the suspected lesion"

A limited lesion or disease was reconfirmed , with a low SCORE , which was locally controlled with breast preserving Surgery and selective axillary dissection ". The patient was sent then to Medical Oncology Unit and Radiotherapy for Standard Therapy.

Prospective protocols could confirm the next HYPOTHESIS :

"LOW IR-SCORE : Localized Disease - ¨Possible Negative Lymph Nodes -Negative HER2neu Status - Positive Hormonal Recpetor Status ."

Could Unify Criteria between Breast Cancer Doctors ( Surgeons , Radiologists , Medical Oncologists and Radiotherapists) :

1. Initial Treatment Option ,
2. Association to Lymph Node Positivity : Sentinel Lymph Node Cost Benefit Use.
3. Predictive Values for HER 2 neu Hormonal Receptors
4. Microvascular Density etc...

" BREAST CANCER CHARACTERISTIC INFRARED PATTERNS EXIST IN POSTMENOPAUSAL WOMEN . EMC"

(ir-Pattern)

" IF THE IR ASSYMETRY IS EVIDENT , THEN THE INFRARED IMAGE CAN BE USED AS A ADJUVANT METHOD TO BREAST PHYSICAL EXAM , SPECIALLY IN COUNTRIES WERE MAMMOGRAPHY IS NOT WIDELY AVAILABLE.

THIS WOULD DOWNSTAGE THEIR CURRENT TUMOR SIZE AVERAGE .

AND WE WOULD STILL RECOMMEND MAMOMMAGRAM AND ULTRASOUND AS THE STANDARD OF CARE FOR SMALLER LESIONS."

EMC :

(ir-Xplore)

ir Image , does not stands as a substitute for mammogram , yet the Breast Cancer as a problem is serious , the numbers do not lie and it offers as an option to be reexplored under the most strict ethical protocols. "ir Image could aid and benefit"