Screening can only detect slow cancers


Observation of our colleague, Dr. Granger, Senology Specialist, November 2021Cancer with high invasive potential, Mrs. NP

Cancer with high invasive potential, Mrs. NP

Mrs. NP, 53 years old, consulted following her last breast assessment, classified ACR 4 due to discovering an attenuating ultrasound lesion in the left breast. There would finally be nothing suspicious after a quick micro biopsy and MRI.

Mrs. NP, wonders, however, what “truth” is hidden behind this “ACR 4” that has suddenly become “non-suspicious” and what follow-up I can provide her.

Clinically, her breasts are soft and regular, with no discernible nodules. There was no discharge or adenopathy. The mammogram reveals dense fibrosis: if the images were considered “normal,” they are very uninformative due to the opacity of the tissues, and we can only note the absence of calcifications. Ultrasound confirmed the presence of multiple disseminated hypoechoic areas. At the intersection of the left external quadrants, the most important one is effectively attenuating and evokes in priority an old cystic structure, rounded and finely echogenic. Puncture under ultrasound guidance with an 18 G needle allows evacuation of a pasty serosa perfectly translucent and homogeneous on the slide: a simple gel cyst.

Conclusion: a typical gel cyst (cytology of the smear will confirm). A one-year ultrasound examination is recommended.

Monitoring was uneventful for 4 years. Then a new check-up revealed the appearance of a hypoechogenic lacuna with irregular contours about 5 mm in diameter, of very doubtful appearance, in the right supra-internal part (i.e., contralateral to the initial cystic image): its puncture under the guidance, was poor, a slide was taken for cytological analysis. This puncture will be acellular, therefore not informative: further investigations are necessary.

The 3-month check-up by palpation revealed the presence of a slightly firmer and poorly bounded area, which had not previously been noted. The hypoechogenic lacuna was verticalized on some sections (a significant sign of malignancy), absorbing, measuring 3 to 6 mm depending on the section axis, and most likely mitotic.

Conclusion: the presence of a very suspicious ultrasound lesion in the right supra-internal region which needs to be excised after ultrasound localization. Because the lesion was so small, a micro biopsy was not performed to avoid diluting it for a proper definitive histological examination (instructions from my anatomo-pathologist).

The chosen surgeon will agree to proceed “the old way” based solely on my ultrasound imaging. Histological diagnosis: infiltrating lobular carcinoma with two foci of 2 and 4 mm, separated by less than 5 mm, moderately differentiated (SBR 2), and peri-nervous sheathing. The lymph node dissection involves the removal of two massively metastatic lymph nodes. Chemotherapy, radiotherapy, and hormone therapy will be used in the treatment.

The first nine years are a “remission” phase. After that, there was a significant increase in CA 15-3, from 28 (normal value for the laboratory) to 48 U/ml in one year. A PET scan revealed a single hypermetabolic lesion of the scapula. Biopsy confirmed the lesion’s metastatic nature, which is consistent with its known breast origin. A focused EBRT was carried out (inclusion in the STEREO-OS trial).

After 3 months, monitoring PET scans will reveal the appearance of new iliac, costal, and clavicular hypermetabolic foci.

This observation, which is still ongoing, raises at least two particular points for Senology practice and Screening.

1 – The initial senological evaluation classified as ACR 4 immediately triggered micro biopsy and MRI: this heavy artillery, set off and organized by the radiologist himself, without any concertation, may have “reassured” him… but not the patient, who was left without a precise diagnosis of the anomaly.

One simple procedure was needed to clarify the problem: a puncture with a fine needle under ultrasound guidance.

This overlooked technique often provides the correct answer: a simple glance at the slide with a light spot is reassuring, revealing a thin, homogeneous, and translucent layer pathognomonic of an old gel cyst. As a reminder: a simple blue needle (6/10th of external diameter, i.e., 23G) is all that is needed; the procedure is painless, much less invasive than a micro-biopsy, and twice as less expensive in the nomenclature of medical procedures).

If this puncture is performed with an 18G needle, the cyst is usually completely evacuated, depending on the degree of cyst gelation. And this immediately reassures everyone, including the patient, even before the subsequent laboratory reading.

This point concludes that our response must be graduated to avoid turning a simple, functional detail – breast cysts being extremely common during the menopausal period – into a nightmare for the patient and ruin for the health insurance system.

2 – The discovery of an abnormality in the other breast four years later did not result in such a simple diagnosis. The clinical examination and mammography were normal, as they had been the last time, but the ultrasound was suspect. The puncture proved inconclusive, necessitating close monitoring.

I would like to point out that 3 months later, the clinical status had become clear, and the imaging was more obvious. The surgery done at the same time showed a very progressive cancer since it was bifocal from the start, although small, with two massively invaded lymph nodes and phenomena of nerve sheathing, with a poor prognosis. After a few asymptomatic years, a series of bone localizations appeared quickly after the first one, confirming an all-sided evolution. The remission was only apparent; the cancer was preparing to explode.

This observation illustrates a case of cancer with high invasive potential: these cancers are always one step ahead, and we just follow their galloping tracks. They constantly put us in failure, and it is indeed against this type of cancer that a screening, even very voluntarist, is ineffective.

Screening, like all screenings, can only detect slowly progressing cancers with a good spontaneous prognosis.

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