tag:blogger.com,1999:blog-30499448.post2272919125096333413..comments2024-02-18T13:53:30.168-08:00Comments on Surgeonsblog: Take Your LumpsSid Schwabhttp://www.blogger.com/profile/14182853083503404098noreply@blogger.comBlogger14125tag:blogger.com,1999:blog-30499448.post-4138017799443658482006-11-29T07:36:00.000-08:002006-11-29T07:36:00.000-08:00Very interesting observations. Does it ever work ...Very interesting observations. Does it ever work the opposite way? Because he elicited a nipple discharge during my breats exam, my OB-GYN referred me for diagnostic mammogram and ultrasound and also referred me to a general surgeon. He could feel no lump or papilloma and neither the mammogram nor the ultrasound showed anything suspicious at all. Does it make sense to follow up with a surgeon if there is nothing to feel or see? Been calling my OB-GYN for two weeks to ask this question and keep getting the message that he's still waiting for the report. What is a surgeon's role in this type of situation?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-30833824902037552182006-10-02T19:40:00.000-07:002006-10-02T19:40:00.000-07:00See, the problem is there's absolutely NO reason t...See, the problem is there's absolutely NO reason to ultrasound a lump after it's been aspirated. It gives no useful information, as you have pointed out. If a lump fails to resolve after aspiration, first of all the aspirate should be evaluated pathologically, and then it needs either to be followed very carefully or undergo surgical biopsy. Again, it depends on who's doing the aspiration: someone who knows what he/she's doing, or not. There remains no reason to ultrasound a palpable lump, unless the woman absolutely refuses needle aspiration, or unless the person holding the needle doesn't have the operating manual.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-74896260119763790562006-10-02T19:12:00.000-07:002006-10-02T19:12:00.000-07:00I am a radiologist. I have seen a number of cases...I am a radiologist. I have seen a number of cases where a breast lump had been aspirated and it did not resolve. I am then asked to ultrasound the mass. By ultrasound the lump is a bloody mess. Is it a bloody mess because that is what it is, or because it has been aspirated? I have seen such lesions resolve in several months time, and also seen them persist and turn out to be malignant. The patients were of course dismayed by the delay in diagnosis. If I get first crack, I can diagnose a simple cyst with certainty. If I don't get first crack, then I am forced to recommend biopsy on what may have initially been a simple cyst.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-89217638731228644822006-10-01T19:42:00.000-07:002006-10-01T19:42:00.000-07:00great commentary. i especially agree with the pan...great commentary. i especially agree with the pandora's box of unnecessary imaging. thanks for the good case illustration re: the breast lump. i refer them all to the local breast surgeon for consultation and bx.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-13891142842379551882006-10-01T08:18:00.000-07:002006-10-01T08:18:00.000-07:00Dr. Schwab, THank you for this civilized discussi...Dr. Schwab, THank you for this civilized discussion on the differences in apporach to a clinical problem that we have with our colleagues-in this case radiologists. It's a shame that we live in a society in which these folk have to adopt such a CYA atttitude, that it complicates the life of the patients and treating physicians and surgeons. <br /><br />As Nuke points out, it's a two-way street, with excessive request for imaging studies by clinicians, and most dramatically the situation in which a patient is diagnosed and triaged on the basis of imaging studies alone, before a physical examination has been performed. <br /><br /> You will find a tremendous amount of bluster and defensiveness on other medblogs with respect to this issue of "tests vs. physical examination." It's sad that a number of our colleagues no longer believe in the value, accuracy or efficacy of good clinical skills. I see this dichotomy primarily between surgical types and medical types. It also seems to be a generational thing, so to some extend it probably reflects the teaching curriculum in medical schols and residencies.No Acute Distresshttps://www.blogger.com/profile/11863597576862907197noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-71890777136803786222006-09-30T12:44:00.000-07:002006-09-30T12:44:00.000-07:00anonymous at 33, That's why I posted my account, t...anonymous at 33, That's why I posted my account, to caution Dr.s about us young ones getting this horrible disease. We need them to know how young we are getting this. Please join us at www.youngsurvival.org and find some comfort and support. Many are going through what you are too.<br />If I can save just one life by saying please investigate this, even if they are 16, because we've had them. In the young, they are usually extremely aggressive cancers.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-48932934848905250992006-09-30T08:18:00.000-07:002006-09-30T08:18:00.000-07:00Nuke: I much preferred to diagnose an appy by exam...Nuke: I much preferred to diagnose an appy by exam. Hardly ordered CTs. But, as you say, that's pretty much out the window, for various reasons. Nor am I unmindful of the "cover your ass" aspect of lots of testing, pulmonary angios being one.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-68512038895043314892006-09-30T07:31:00.000-07:002006-09-30T07:31:00.000-07:00As a Radiologist, all I can say is we try our best...As a Radiologist, all I can say is we try our best. In the aboce mentioned "white matter disease" post, I frequently will describe it as of doubtful significance in my impression..you see it in most MRI's in people over 40....it just isn't a good descriminator in pathology.<br /><br />What I can tell you is I continue to be amazed at the over utilization of imaging. 15 CT pulmonary angio studies in 6 months, all normal, on young 30 year old people..25 CT's of the abdomen in a year on a 40 year old with chronic abdominal pain..all normal. <br /><br />I love when an old crusty surgeon comes in and says.."They's got an appy, they already got the CT, do you agree?". The young guys come in and say "I haven't seen the patient, labs, or looked at the chart, can you tell me what's wrong?"<br /><br />Imaging is good....but like everything, it comes with significant downsides.nuclearvisionhttps://www.blogger.com/profile/15234802591459481539noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-63987066101642233682006-09-30T06:53:00.000-07:002006-09-30T06:53:00.000-07:00anonymous: that's part of my point. Ultrasound isn...anonymous: that's part of my point. Ultrasound isn't very good beyond telling if it's a cyst or not. If yours was cancer, it wasn't a cyst, and therefore, no matter what the report said, badness couldn't have been ruled out. Since your lump was feelable, my approach is that it never would have had an ultrasound.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-51694471870240399952006-09-30T00:10:00.000-07:002006-09-30T00:10:00.000-07:00at 33, my lump's ultrasound suggested nothing to w...at 33, my lump's ultrasound suggested nothing to worry about so I didnt worry but had a surgeon take the lump out anyway just over two months later (I had already had a benign lump removed a couple of years before) - thats when it was found it was cancer after all - 6 yrs and lots of treatment later Im now terminal.<br /><br />I can't be sure if I had had a needle biopsy things would have been much different but I hate to think about if I hadnt had the surgery...Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-63463183636405222292006-09-29T16:45:00.000-07:002006-09-29T16:45:00.000-07:00I would caution the Dr.s that say after 35yrs. of ...I would caution the Dr.s that say after 35yrs. of age, they wouldn't skip it.( I commend them, however, for not waiting until 40 and poo pooing them until then.) Check out<br />www.youngsurvival.org. We are younger and younger with very aggressive cancers in the breast. I think the guidelines of "after 40" are crazy. We are in our 20's and 30's being diagnosed at stages 2b and 3. I was lucky and called a surgeon right away. My Gyn said he "didn't feel anything." My surgeon, Gd love him, couldn't find it on palpation. I put a pen marked x on it. He went right in, right then and biopsied. Yep, cancer, but in two areas. Needed the mammogram to tell us that, but was no where near 40.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-52984012865368550592006-09-29T16:44:00.000-07:002006-09-29T16:44:00.000-07:00#1 dino: Fact is, I've tried to get primary care d...#1 dino: Fact is, I've tried to get primary care docs to do their own aspirations. Good for you! Also, I entirely agree that a simple recheck (after the next period in a premenopausal woman, or in a couple of weeks) is a great first step in a lesion that may not be a lesion. And I assume you meant to say that ultrasound is for a NON palpable mass! Nor would I omit mammogram; it's a question of when. And I totally agree about MR. Finally; I didn't mean to be attacking primary care docs, if that's how it came off. I do wish there were more consistency in approaches to certain surgical problems, especially breast lumps. The way to get there is by cooperation and feedback. In the best of all worlds....<br /><br />Greg: I'm with you 100%. I got into trouble at a conference between radiologists and surgeons, called because of rising unhappiness over readings that direct care, make various suggestions. I said "When all you have is a hammer, everything starts to look like a nail." Not politic, in retrospect. But the point is serious: everyone (including the patient, as you point out) gets put in a hole by radiology reports that go overboard. I realize the radiologist has to cover his/her rear as well. Again, in an ideal world, we'd talk amongst ourselves more. And we'd have time to do it!!Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-52181410280073890352006-09-29T16:07:00.000-07:002006-09-29T16:07:00.000-07:00Nonetheless, I think the gist of the commentary is...Nonetheless, I think the gist of the commentary is right.<br />I'm not a surgeon, I'm a neurologist, and I see so many patients that have had X-rays, CTs, MRs, EEGs, EMGs, blood tests, none of which individually or in concert are able to come to some conclusion, then FINALLY a neurologic consultation is obtained.<br />We have a legal protective attitude these days, and especially when you are asking someone to take a stand based on some lab numbers, some pixels on a PC monitor, without ever having seen or talked to the patient you get defensiveness:<br />"Cannot exclude..."<br />"An MRI may be more informative..."<br /><br />Every year I see several patients who come as a "possible MS" (multiple sclerosis), strictly based on a radiologist's comment about "white matter lesions." All without any connections to symptoms, physical findings or really any knowledge whatsoever of the person who had the test. I've had patients' scans in which I struggle to even FIND the "white matter lesions" that are referred to in the report.<br />This isn't a situation where it's just a little wasted money, and I can be a savior by saying, "Well, don't worry, you don't have MS," I'm dealing with someone who's been frightened out of their wits.<br />The other thing I know is that some screwball in his legally defensive radiology report has just screwed this person's chances of getting reasonably priced health insurance, life insurance, maybe a job, because that report is out there and can't be modified, corrected, or destroyed and can be found by someone as soon as the consent for information is signed.Greg Phttps://www.blogger.com/profile/18422487877167541900noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-57109080184158350412006-09-29T15:05:00.000-07:002006-09-29T15:05:00.000-07:00Whoa! Down, boy. I share your disdain for the radi...Whoa! Down, boy. I share your disdain for the radio-illogical merry-go-round, but back off a bit on those jabs at us Primaries. That said, I agree with pretty much everything substantive in your post.<br /><br />The thing I often have to figure out, though, is whether something a woman points out to me is in fact a lump, or just lumpy breast tissue. I'll often re-examine the area in two weeks (different part of the menstrual cycle) and I've been known to jab a needle into those persistent lumps myself and drain those cysts. Poor patient never even gets to meet Dr. Sid.<br /><br />I agree that the purpose of ultrasound is to characterize a palpable mass, but I never skip the mammogram (after about age 35.) You'd be amazed at how often Gd puts a benign cyst in one breast to get a woman to the doctor so the non-palpable cancer in the other breast can be discovered and treated early.<br /><br />By the way, the latest most useless radiographical ploy is breast MR; the ultimate waste of time and money.#1 Dinosaurhttps://www.blogger.com/profile/01357845504444464397noreply@blogger.com