CONTACTS 

SUBJECTS
Meeting Surgeon Evaluate Mastectomy Left Breast Follow Up Examinatio

0503 -
0503 -    ..
0504 - Summary/Objective
0505 -
050501 - Follow up ref SDS 44 0000. ref SDS 41 0000.
050502 -
050503 - Examination indicates Millie is recovering normally from mastectomy
050504 - surgery.  Biopsy found no evidence of inflammatory carcinoma in the
050505 - breast. ref SDS 0 RI6I  The doctor said Millie is now disease-free.
050506 - ref SDS 0 M58G  She removed the surgery drain tubes; this hurt, but
050507 - was done quickly without incident. ref SDS 0 RD3M  The surgeon feels
050508 - Millie's stage IV patient profile recovering from secondary IBC
050509 - requires frequent, vigorous testing for the near term to assess
050510 - relapse. ref SDS 0 L05O  The surgeon is counting on team care in the
050511 - Oncology Department to schedule timely examinations for relapse,
050512 - following the practice that diagnosed IBC in 2004. ref SDS 0 OZ70  The
050513 - biopsy showing no evidence of IBC, reports evidence of new cancer:
050514 - ductal carcinoma in situ (DCIS). ref SDS 0 615K  Millie does not seem
050515 - to have any risk factors for DCIS; recent PET and mammogram testing
050516 - found no evidence of disease.  Test failures in Millie's case,
050517 - ref SDS 0 BA3O, present a risk of DCIS in the right breast that has
050518 - likewise passed detection, based on persistent elevated cancer
050519 - diagnostic, CA 15-3.  Further review of disease-free status seems
050520 - required. ref SDS 0 BA5G  Surgeon is checking with Oncology for follow
050521 - up investigation. ref SDS 0 2562
050522 -
050523 -     [On 060217 PET scan test finds no evidence metastatic disease;
050524 -     doctor describes swelling left axilla as post op localized edema.
050525 -     ref SDS 56 T56K
050527 -      ..
050528 -     [On 060623 red rash and rising CA 15-3 indicate IBC cancer relapse
050529 -     8 months after surgery. ref SDS 63 025H
050530 -
050531 -
050532 -
050533 -
050535 -  ..
0506 -
0507 -
0508 - Progress
0509 -
050901 - The following agenda guided discussions...
050902 -
050903 -        Examination............................. ref SDS 0 RI6I
050904 -        Biopsy results and assessment........... ref SDS 0 U05M
050905 -        Relapse testing......................... ref SDS 0 L05O
050906 -        Biopsy retest for treatment options..... ref SDS 0 964L
050907 -        Pulmonary emboli........................ ref SDS 0 6Y7X
050908 -        Port catheter flush schedule............ ref SDS 0 918G
050909 -        Medical leave recovery requirements..... ref SDS 0 5Q3H
050910 -
050911 -
050912 -
050913 -
050914 -
0510 -

SUBJECTS
Successful Mastectomy Surgery Clear Margins Reported Based on Testin
Scope Surgery Very Wide Mastectomy Oval Beyond Test Biopsies at Top
Disease-free Status Complete Response to Treatment Tests Demonstrate

2305 -
230601 -  ..
230602 - Status Disease-free Following Successful Mastectomy Surgery
230603 - Disease-free Survival Status Based on Testing and Examination
230604 - Complete Response to Treatment Local Control Disease-free Status
230605 - Examination Surgical Wound Healing Normally, Drain Tubes Removed
230606 -
230607 - Follow up ref SDS 44 EG5L.
230608 -
230609 - The doctor was very pleased with Millie's progress recovering from
230610 - surgery, and indicated examination shows the surgical wound is healing
230611 - normally in all respects, despite diagnosis of inflammatory breast
230612 - cancer (IBC), and thus indicating success of systemic treatment this
230613 - past year, as shown by the PET scan test report received on 051007,
230614 - ref SDS 37 L66M, and further by the biopsy on tissue from surgery
230615 - performed on 051021, as shown below. ref SDS 0 U05M
230616 -
230617 -     [On 051121 examination by primary care physician in Oncology
230618 -     Department shows surgery wound healing without complications.
230619 -     ref SDS 51 025H
230621 -      ..
230622 -     [On 051125 Millie reported slight seepage from the surgical wound,
230623 -     only evident in stained clothing. ref SDS 52 025H  Kaiser was
230624 -     notified. ref SDS 52 LC7M
230625 -      ..
230626 -     [On 051129 Millie reported further slight seepage. ref SDS 53
230627 -     025H
230628 -     .
230629 -      ..
230630 -     [On 051129 Diane at Kaiser called back; she contacted the
230631 -     surgeon, and reported later than a meeting is scheduled for
230632 -     051202 to review the problem. ref SDS 53 JG7G
230634 -      ..
230635 -     [On 051202 surgeon examination to determine cause of slight
230636 -     seepage; speculates may arise from drain tube system removed
230637 -     today. ref SDS 54 XO8O
230639 -      ..
230640 -     [On 060217 PET scan test finds no evidence metastatic disease;
230641 -     doctor describes swelling left axilla as post op localized edema.
230642 -     ref SDS 56 T56K
230644 -  ..
230645 - Examination today supports recent patient history listed on 050812
230646 - showing favorable response to treatment for secondary IBC. ref SDS 23
230647 - AV5M
230649 -  ..
230650 - The doctor said the biopsy found clear margins, and so reexcision,
230651 - required following the first surgery on 020327, ref SDS 3 0001, will
230652 - not be needed in this case. ref SDS 0 616P  She said pre-cancerous
230653 - "funny stuff" was found near the nipple, but could have become
230654 - cancerous later. (see below, the biopsy found cells consistent with
230655 - DCIS, ref SDS 0 615K)  The doctor feels that surgery on 051021 reduced
230656 - the risk of relapse, cited previously on 051007 by the primary care
230657 - physician, as grounds for palliation surgery. ref SDS 37 I482
230658 -
230659 -    [On 060623 red rash and rising CA 15-3 indicate IBC cancer relapse
230660 -    8 months after surgery. ref SDS 63 025H
230662 -  ..
230663 - The doctor clarified initial impressions from post-op reporting on
230664 - 051021, ref SDS 44 MM6M, citing plans on 050724 for a wider than
230665 - normal mastectomy. ref SDS 22 TI7O
230667 -  ..
230668 - The doctor's post-operative surgery report is incorporated into the
230669 - record on 051021. ref SDS 44 369L  This report describes an elliptical
230670 - incision to establish the scope of breast removal. ref SDS 44 TH50
230672 -  ..
230673 - Today, the surgeon described having performed a standard mastectomy
230674 - that implemented her report received on 050927, ref SDS 34 EU67, which
230675 - presented understandings from meeting on 050923. ref SDS 33 4G4L  The
230676 - surgical incision formed a very wide oval extending just above and
230677 - just below test biopsies at the top and the bottom of the left breast,
230678 - as recommended by Doctor Grissom on 050920, ref SDS 30 XL7P, and were
230679 - later performed on 051012, ref SDS 41 DG6J, for the purpose of setting
230680 - mastectomy scope planned with the surgeon on 050923 for reducing the
230681 - risk of relapse by removing the entire left breast previously
230682 - irradiated and infected with IBC. ref SDS 33 NT9G  Surgical removal
230683 - beyond the test biopsies helped remove microscopic cancer cells, cited
230684 - as a continuing risk of relapse by the surgeon on 050923, ref SDS 33
230685 - KF6I, and supported by the primary care physician on 051007.
230686 - ref SDS 37 IV4G
230687 -
230688 -    [On 060711 patient diagnosed IBC relapse left breast.
230689 -    ref SDS 64 025H
230691 -  ..
230692 - Since the scope of removal was beyond the test biopsies, the surgery
230693 - may align with Doctor Grissom's ideas for a "very wide mastectomy"
230694 - defined by radiation tattoos, as proposed in a letter received on
230695 - 050920. ref SDS 30 XL8U  Surgical incision seems to have cut through
230696 - skin above the breast which was previously infected with IBC that
230697 - spread toward the neck, cited by the surgeon on 050324. ref SDS 19
230698 - YY7F  Doctor Bailey described in a 2nd opinion received on 050922
230699 - risks that this procedure can prevent healing of the surgical wound.
230700 - ref SDS 31 XD8P  Examination today indicates normal healing has
230701 - occurred so far, so possibly this risk will not become manifest with
230702 - post-op problems.
230703 -
230704 -    [On 060711 diagnosis IBC relapse left breast may indicate surgery
230705 -    was not wide enough. ref SDS 64 025H
230707 -  ..
230708 - The doctor seemed to indicate today that successfully stretching skin
230709 - and tissue to perform a standard closure for a very wide mastectomy
230710 - has maintained adequate blood supply for delivering nutrients and
230711 - treatment, if necessary, to the skin, so that the wound and any
230712 - subsequent IBC relapse will heal for palliation, cited in the letter
230713 - prepared on 051019, ref SDS 43 DZ4W, and mentioned in Doctor Bailey's
230714 - 2nd opinion consultation on 051011, ref SDS 39 G65S, reflecting Doctor
230715 - Smith's risk analysis earlier at Kaiser on 050928. ref SDS 35 248I
230717 -  ..
230718 - Just before starting the operation on 051021, Millie asked the surgeon
230719 - about the purpose of mastectomy.  The surgeon cited palliation,
230720 - ref SDS 44 8L9K, first presented by the primary care physician on
230721 - 051007, ref SDS 37 6A4N, who, as noted, grounded surgery for
230722 - palliation on possibility of relapse caused by microscopic cancer
230723 - cells not detected by tests, ref SDS 37 IV4G, and supported by Doctor
230724 - Smith's notes received on 051007 citing palliation, but not presented
230725 - to the patient during a meeting on 050928.
230727 -  ..
230728 - The doctor said today that Millie's status is "disease-free," which
230729 - demonstrates progress toward "local control."  No evidence of disease
230730 - (NED) in the biopsy report today may demonstrate complete response to
230731 - treatment, and aligns with the PET scan test report received on
230732 - 051007. ref SDS 37 0001
230734 -  ..
230735 - Millie was pleased hearing from the doctor that mastectomy surgery
230736 - ordered on 051007 for palliation, ref SDS 37 MW6O, and performed on
230737 - 051021, ref SDS 44 EG5L, compliments prior findings that she is now
230738 - "disease-free," and further that removing pre-cancerous tissue may
230739 - have prevented future relapse. ref SDS 0 RI6I
230740 -
230741 -        [...see below, disease-free status requires review of DCIS in
230742 -        right breast. ref SDS 0 BA5G
230744 -         ..
230745 -        [On 051121 primary care physician finds patient has no evidence
230746 -        of disease (NED) based on estensive testing with biopsy, PET,
230747 -        CA 1503; prognosis is for future relapse due to diagnosis of
230748 -        metastatic cancer, and therefore mastectomy surgery on 051021
230749 -        was palliation for furture relapse. ref SDS 51 LH7M
230751 -         ..
230752 -        [On 060217 PET scan test finds no evidence metastatic disease;
230753 -        doctor describes swelling left axilla as post op localized
230754 -        edema. ref SDS 56 T56K
230756 -         ..
230757 -        [On 060711 patient diagnosed IBC relapse left breast.
230758 -        ref SDS 64 025H
230760 -  ..
230761 - Determination of disease-free status reflects finding no evidence of
230762 - local, regional, nor distant metastatic disease, as shown by the PET
230763 - scan test reported on 051007, ref SDS 37 L66M, and the biopsy report
230764 - from surgery on 051021, shown below. ref SDS 0 U05M  This aligns with
230765 - the surgeon's report on 050927 saying mastectomy surgery was for local
230766 - control, ref SDS 34 AK4Q, previously discussed on 050923. ref SDS 33
230767 - O15H  The doctor noted that testing in the coming weeks and months
230768 - will show whether cancer is in remission.  Disease-free status is the
230769 - first step demonstrating local control, essential for cure presented
230770 - in the 2nd opinion received on 050907, ref SDS 25 F49H, and later
230771 - discussed with Doctor Grissom on 051010. ref SDS 38 GW5K
230773 -         ..
230774 -        [...see below, on follow up testing to monitor risk of relapse.
230775 -        ref SDS 0 L05O
230777 -         ..
230778 -        [On 060711 patient diagnosed IBC relapse left breast.
230779 -        ref SDS 64 025H
230780 -
230781 -
230782 -
230783 -
2308 -

SUBJECTS
Case Study Purpose Mastectomy for Secondary IBC Relapse Risks from R

4303 -
430401 -  ..
430402 - Case Study Purpose of Mastectomy for Secondary IBC
430403 - Relapse Risks from Residual Microscopic Cancer Cells
430404 - Innovation for Mastectomy Surgery Secondary IBC Patient
430405 - Purpose of Surgery Palliation Remission Recurrence-free Cure
430406 -
430407 - Follow up ref SDS 37 MW5O, ref SDS 16 657F.
430408 -
430409 - Surgeon's initial presentation on 051021 for the scope of surgery
430410 - suggested possible innovation to perform a very wide mastectomy that
430411 - reduces risk of relapse and also avoids risk of complications from
430412 - immediate reconstruction. ref SDS 44 MP8K  Discussion during the
430413 - meeting today, ref SDS 0 RA3H, clarified first impressions on what was
430414 - done and why, ref SDS 0 QY8K, and further complements prior studies on
430415 - 051007 that reviewed history proposing surgery for local control in
430416 - relation to new theory of palliation, ref SDS 37 MW5O, and earlier on
430417 - 041210 showing entire history considering surgery for Millie.
430418 - ref SDS 16 657F  In any case, research on the Internet does not reveal
430419 - treatment of primary or secondary IBC for the purpose of removing
430420 - previously infected skin to reduce the risk of relapse, leading to
430421 - remission and possibly cure.  Additionally, Doctor Grissom noted on
430422 - 050920 that Millie may present a case of first impression. ref SDS 30
430423 - XL9Y  Therefore, the record may be helpful for others who travel this
430424 - road in the future.
430426 -  ..
430427 - Case study on all considerations for surgery is reported on 041210.
430428 - ref SDS 16 657F
430430 -  ..
430431 - Chronology on purpose of surgery...
430432 -
430433 -        1.  Cure opportunity presented
430434 -            by patient profile cited in
430435 -            2nd opinion consultation with
430436 -            Doctor Grissom................... 051010, ref SDS 38 GW4I
430438 -             ..
430439 -        2.  Cure goal of surgery proposed
430440 -            by Kaiser surgeon internal
430441 -            referral......................... 050907, ref SDS 25 F49H
430442 -            setting stage III status......... 050826, ref SDS 24 F49H
430444 -             ..
430445 -        3.  Cure requires avoiding relapse
430446 -            at risk from microscopic cancer
430447 -            cells in previously infected
430448 -            areas, cited by primary care
430449 -            physician........................ 051007, ref SDS 37 I482
430451 -             ..
430452 -        4.  Microscopic cancer cells
430453 -            present risk of relapse, also,
430454 -            cited by surgeon................. 050923, ref SDS 33 KF6I
430456 -             ..
430457 -        5.  Avoiding cancer relapse
430458 -            requires treating locoregional
430459 -            sites for patient profile with
430460 -            history of tests over 4 years
430461 -            finding no distant metastatic
430462 -            disease.......................... 051007, ref SDS 37 AG6G
430464 -             ..
430465 -        6.  Primary local site is left
430466 -            breast where IBC infected
430467 -            the skin from below the nipple
430468 -            and extended beyond the breast
430469 -            toward the neck noted in
430470 -            examination by surgeon, but
430471 -            without accurate report on
430472 -            scope of disease with diagrams
430473 -            and photographs to later guide
430474 -            treatment with surgery........... 050324, ref SDS 19 YY7F
430476 -             ..
430477 -        7.  Scope of left breast removal
430478 -            with mastectomy surgery was
430479 -            initially not determinable
430480 -            because surgeon was not
430481 -            experienced treating
430482 -            IBC.............................. 050324, ref SDS 19 WH5L
430484 -             ..
430485 -        8.  Doctor calls surgeon to schedule
430486 -            mastectomy for the purpose of
430487 -            local control because observes
430488 -            cancer worsening in left breast
430489 -            due to pockets of resistance
430490 -            to chemotherapy
430491 -            treatment........................ 050311, ref SDS 18 XQ41
430493 -             ..
430494 -        9.  Mastectomy to treat primary IBC
430495 -            presented in published guidance
430496 -            calls for surgery when IBC has
430497 -            not spread beyond the breast,
430498 -            and for the purpose of removing
430499 -            a tumor from within the
430500 -            breast........................... 040517, ref SDS 11 YM3M
430502 -             ..
430503 -       10.  Mastectomy can lead to cure for
430504 -            stage I and II patients, and in
430505 -            some cases Stage III patients;
430506 -            stage IV cancer patients get
430507 -            palliation treatment............. 050712, ref SDS 21 B65G
430509 -             ..
430510 -       11.  Doctor Benz classifies Millie
430511 -            diagnosed with secondary IBC
430512 -            as stage III based on standards
430513 -            and practice at UCSF............. 041018, ref SDS 13 EO3Y
430514 -            and maintained there is no
430515 -            role for surgery................. 041117, ref SDS 14 OU5P
430517 -             ..
430518 -       12.  Primary care physician classifies
430519 -            same patient profile diagnosis
430520 -            IBC on relapse as stage IV
430521 -            based on standards and practice
430522 -            at Kaiser........................ 040614, ref SDS 12 SZ3I
430523 -            and proposed surgery for
430524 -            local control.................... 051007, ref SDS 37 5W7F
430525 -            then changed purpose to
430526 -            palliation....................... 051007, ref SDS 37 6A4N
430528 -             ..
430529 -       13.  Surgeon proposed wider than
430530 -            normal scope for laying out
430531 -            mastectomy incision to treat
430532 -            Millie's patient profile with
430533 -            history of secondary IBC
430534 -            infection spreading toward
430535 -            the neck and no evidence
430536 -            of tumor within the
430537 -            breast........................... 050727, ref SDS 22 JV5F
430539 -             ..
430540 -       14.  Doctor Grissom proposed
430541 -            laying out very wide mastectomy
430542 -            to remove previously irradiated
430543 -            skin based on radiology
430544 -            tattoos.......................... 050920, ref SDS 30 XL8U
430545 -            and thin skin biopsies
430546 -            indicating limits of prior
430547 -            IBC infection to obtain
430548 -            negative margins that reduce
430549 -            risk of relapse.................. 050920, ref SDS 30 GT3M
430550 -            Doctor Bailey similarly
430551 -            proposed removing a very large
430552 -            area to remove all previously
430553 -            involved skin, if mastectomy
430554 -            surgery was attempted for
430555 -            Millie's patient profile of
430556 -            secondary IBC.................... 050922, ref SDS 31 XD8P
430558 -             ..
430559 -       15.  Regional sites on left side
430560 -            of neck found cancerous and
430561 -            recommended for surgical
430562 -            removal.......................... 040303, ref SDS 6 Y193
430563 -            but surgery was not actually
430564 -            performed and so may be a
430565 -            site where microscopic cancer
430566 -            cells can cause relapse cited
430567 -            by surgeon....................... 050923, ref SDS 33 VL4O
430569 -             ..
430570 -       16.  Research finds no published
430571 -            guidance for "wide" nor "very
430572 -            wide" mastectomy to remove
430573 -            skin previously irradiated
430574 -            and infected with IBC in
430575 -            order to reduce the risk
430576 -            of relapse....................... 051021, ref SDS 44 QD7G
430578 -             ..
430579 -       17.  Local control in left breast
430580 -            using surgery, see case
430581 -            study............................ 051007, ref SDS 37 MW5O
430582 -            largely fits requirements for
430583 -            wider than normal mastectomy
430584 -            using biopsies to guide layout
430585 -            that achieved clear margins,
430586 -            even though all of the skin
430587 -            previously infected may not
430588 -            have been removed, and thus
430589 -            leaving open the prospect that
430590 -            microscopic cancer cells may
430591 -            yet cause local control to
430592 -            fail............................. 051027, ref SDS 0 JN3L
430594 -             ..
430595 -       18.  Regional sites include left
430596 -            axilla recommended for
430597 -            another node dissection, which
430598 -            was not performed to avoid
430599 -            lymphedema; and right axillary
430600 -            where issues have not been
430601 -            expressly reported to be totally
430602 -            resolved; therefore, microscopic
430603 -            cancer cells may remain that
430604 -            cause relapse, based on patient
430605 -            history of multiple relapse in
430606 -            left axilla...................... 051027, ref SDS 0 LI3K
430608 -             ..
430609 -       19.  Pockets of resistance treatment with
430610 -            mastectomy not a common theory; surgery
430611 -            has 20% chance of long term success
430612 -            for IBC, but IBC very aggressive
430613 -            cancer; correlation to
430614 -            palliation not
430615 -            evident.......................... 070130, ref SDS 66 EH3F
430616 -
430618 -  ..
430619 - This patient history appears to present a continuing risk of relapse
430620 - despite current disease-free status, because the full range of suspect
430621 - sites has not been treated to remove "microscopic cancer cells,
430622 - presented by the surgeon on 050923 for continuing risk of relapse,
430623 - ref SDS 33 KF6I, and presented again by the primary care physician on
430624 - 051007. ref SDS 37 IV4G  On the other hand, the one major site where
430625 - obvious cancer occurred may now be disease-free based on the biopsy
430626 - report. ref SDS 0 U05M
430627 -
430628 -        [On 060711 patient diagnosed IBC relapse left breast.
430629 -        ref SDS 64 025H
430630 -
430631 -
430632 -
430633 -
430634 -
430635 -
4307 -

SUBJECTS
Surgery Drain Tubes and Effluent Discharge Containers Removed Meetin

4503 -
450401 -  ..
450402 - Surgery Drain Tubes and Effluent Discharge Containers Removed
450403 -
450404 - Prior to entering the examination room, the nurse asked Millie how
450405 - much drainage occurred from the surgery last week on 051021?  Millie
450406 - related some figures, reflecting calibrations on the side of the small
450407 - effluent plastic containers connected to the drain tubes.
450408 -
450409 -     [On 051202 surgeon examination to determine cause of slight
450410 -     seepage; speculates may arise from drain tube system removed
450411 -     today. ref SDS 54 XO8O
450413 -  ..
450414 - The doctor said that, based on Millie's report of minimal discharge,
450415 - the surgery drain tubes can be removed today.  This was painful, but
450416 - was quickly and smoothly pulled from penetrations, taking only about a
450417 - second for each of the two (2) tubes.  The drains seem to extend well
450418 - into the body, so extraction was very uncomfortable, but Millie
450419 - recovered quickly.
450420 -
450421 -
450422 -
450423 -
4505 -

SUBJECTS
Orientation Side Effects High Risk IBC Patient Mastectomy Surgery Gu

4803 -
480401 -  ..
480402 - Orientation Guidance Managing Emotional Trauma Mastectomy Surgery
480403 - Side Effects Reaction to Very Wide Mastectomy Orientation Guidance
480404 -
480405 - Due to limited time, the doctor did not discuss side effects of
480406 - physical and emotional trauma that are occurring from wider than
480407 - normal mastectomy surgery reported on 051026, ref SDS 47 KG5I, and
480408 - which may accompany having performed innovative surgery to reduce the
480409 - chance of relapse.
480411 -  ..
480412 - The doctor asked Millie to raise her left arm, and on observing a
480413 - normal range of motion, commented on Millie's strong recovery.
480414 -
480415 -
480416 -
480417 -
480418 -
480419 -
480420 -
4805 -

SUBJECTS
Doctor's Pre-op Patient History Missing May Explain Purpose of Surge

6103 -
610401 -  ..
610402 - Time Out Due Diligence Risk Analysis Scope Purpose of Surgery
610403 - Doctor Pre-op Patient History Missing Explanation Purpose of Surgery
610404 -
610405 - Follow up ref SDS 44 6D4F, ref SDS 41 6D4F.
610406 -
610407 - Pre-op patient history reported missing from Kaiser's records and
610408 - required by the nurse for admitting Millie into the Surgery Department
610409 - on 051021, ref SDS 44 QV4H, may show performance of "Time Out"
610410 - requirements for due diligence in this case, as shown in the letter on
610411 - 051019. ref SDS 43 V55K
610413 -  ..
610414 - The doctor explained today that the pre-op patient history required
610415 - for surgery on 051021 was eventually prepared for Kaiser's records,
610416 - but it is not important nor necessary for the patient to review.  This
610417 - document was not submitted during the meeting.
610419 -  ..
610420 - The pre-op report on patient history may explain the purpose of
610421 - surgery, as required by Kaiser's Time Out due diligence check list,
610422 - reported in the record on 050923, ref SDS 33 HF7M, and cited in the
610423 - letter prepared for implementing these requirements on 051019.
610424 - ref SDS 43 DY5P (see first draft on 051012. ref SDS 41 IA5V)
610426 -  ..
610427 - The was not enough time during the meeting to review the scope for a
610428 - post-op report, per below. ref SDS 0 OZ70
610430 -  ..
610431 - The surgeon's post-op report should explain the work performed, and
610432 - include an as-built diagram showing the actual outline of surgical
610433 - incision.  A narrative should explain how the surgery is different
610434 - from a standard mastectomy, shown in pictures presented by Doctor
610435 - Smith in the Plastic Surgery Department on 050928, ref SDS 35 246J,
610436 - and further explain how a standard closure was accomplished for a
610437 - wider than normal mastectomy.
610439 -       ..
610440 -      [On 051121 surgeon's post-op report was received, and showed no
610441 -      as-built diagram. ref SDS 51 355L
610442 -
610443 -
610444 -
610445 -
6105 -

SUBJECTS
Axillary Node Dissection Not Performed to Remove More Lymph Nodes Do

6403 -
640401 -  ..
640402 - Disease-free Status Analysis Microscopic Cancer Cells in Axilla
640403 - Axillary Node Dissection Not Performed to Avoid Lymphedema
640404 - Lymphedema Risk Avoided Axillary Node Dissection Not Performed
640405 - Lymphadenopathy Patient History of Relapse Balance Against Lymphedema
640406 -
640407 - The doctor confirmed she did not perform axillary node dissection
640408 - because of concern to avoid the risk of lymphedmea.  This confirms
640409 - Millie's report on 051021. ref SDS 44 QU5I  Another axillary node
640410 - dissection was originally proposed for consideration on referral by
640411 - the surgeon in Kaiser's Oakland office on 050907. ref SDS 25 JS4H
640412 - Research shows secondary lymphedema can occur from surgical removal of
640413 - lymph nodes for treating breast cancer....
640415 -          ..
640416 -         http://www.emedicine.com/med/topic2722.htm
640418 -      ..
640419 -     [On 060106 patient reports new swelling, large bulge under left
640420 -     axillary; initial diagnosis is lymphadema. ref SDS 55 S164
640422 -      ..
640423 -     [On 060217 PET scan test finds no evidence metastatic disease;
640424 -     doctor describes swelling left axilla as post op localized edema.
640425 -     ref SDS 56 T56K
640427 -      ..
640428 -     [On 060306 examination at lyphedema clinic showed worsening
640429 -     condition; follow up meeting for personalized treatment scheduled.
640430 -     ref SDS 57 Q05H
640432 -      ..
640433 -     [On 060308 lymphedema symptoms increase, report at work.
640434 -     ref SDS 58 0001
640436 -      ..
640437 -     [On 060314 physical therapy treatment and new guidance for
640438 -     lymphedema; begin regimin of personal massage treatments to reduce
640439 -     swelling left arm. ref SDS 59 Q05H
640441 -      ..
640442 -     [On 060320 letter to primary care physician reports research
640443 -     showing bandage should be worn during exercise; lymphedema may
640444 -     have accelerated because exercise was performed without bandage
640445 -     during exercise for several months prior to notce. ref SDS 60 EU40
640447 -      ..
640448 -     [On 060331 further improvement swelling decreases to 11", best
640449 -     reading in a month indicates lymphedema symptoms decline.
640450 -     ref SDS 61 0001
640452 -      ..
640453 -     [On 060417 therapyst finds decreased swelling, marked improvement
640454 -     compared to examination on 060314; explains that removal of lymph
640455 -     nodes during surgery on 051021 may have triggered increased
640456 -     symptoms of lymphedema. ref SDS 62 2Z9M
640458 -  ..
640459 - Patient history shows continual relapse of cancer in left axilla,
640460 - reported on 040517. ref SDS 11 OW3I  Though there is no corresponding
640461 - history of relapse in the right axilla, recent findings present the
640462 - prospect of distant metastasis, discussed on 051007, ref SDS 37 B58M,
640463 - despite express findings from image tests that state no distant
640464 - metastasis has been identified. ref SDS 37 XU7N
640466 -  ..
640467 - Since the PET scan test on 051005 and received on 051007 showed no
640468 - evidence of cancer in either the left or right axilla, ref SDS 37
640469 - L66M, then axillary node dissection on both the left and right sides
640470 - for the purpose of removing microscopic cancer cells that might
640471 - someday cause relapse may present an unnecessary risk for lymphedema
640472 - relative to risks presented by patient history of relapse, even though
640473 - there is no express finding in the PET scan test resolving prior
640474 - findings of swelled lymph nodes in the right axillary. ref SDS 37 1E8L
640476 -  ..
640477 - Similarly, PET scan and mammogram testing reported no findings of
640478 - ductal carcinoma in situ (DCIS), however, this was found by the biopsy
640479 - report, per below. ref SDS 0 615K  Research shows mammograms are the
640480 - most common test for identifying DCIS, and further that DCIS can
640481 - spread cancer to the axilla lymphatic systems.  This record presents a
640482 - risk of spreading cancer due to microscopic cancer cells that requires
640483 - balance against risk of lymphedema.  How was the balance struck in
640484 - this case?
640485 -
640486 -
640487 -
640488 -
640489 -
640490 -
640491 -
6405 -

SUBJECTS
Surgery Follow Up Examinations Not Scheduled Oncology Department to

7603 -
760401 -  ..
760402 - Surgery Follow Up Not Scheduled Oncology Department to Notify Surgery
760403 -
760404 - Follow up ref SDS 9 PPSW.
760405 -
760406 - After examining progress healing the incision, ref SDS 0 RI6I, and
760407 - removing the drain tubes, ref SDS 0 RD3M, the doctor said the
760408 - examination was completed.  This took about 10 minutes.
760410 -  ..
760411 - The doctor was asked to review the patient's agenda, per above.
760412 - ref SDS 0 DG6J
760414 -  ..
760415 - The surgeon advised that her work plan does not call for more frequent
760416 - monitoring, and special methods and treatment to aid recovery from
760417 - high risk surgery, previously presented in 2nd opinions, and reviewed
760418 - by the surgeon on 050923, ref SDS 33 KF6I, and again by Doctor Smith
760419 - during another examination on 050928. ref SDS 35 9W4I
760420 -
760421 -     [On 060217 PET scan test finds no evidence metastatic disease;
760422 -     doctor describes swelling left axilla as post op localized edema.
760423 -     ref SDS 56 T56K
760425 -  ..
760426 - The doctor said she does not plan to see Millie again, and so no
760427 - follow up examination was scheduled.  This seems conflicting with
760428 - procedure following lumptectomy surgery performed on 020312, and with
760429 - reexcision for clear margins on 020327.  When the surgeon examined the
760430 - patient on 020408, follow up examinations were scheduled for every
760431 - three (3) months. ref SDS 4 WX4K  Later, on 040419 the surgeon
760432 - performed a punch biopsy, which diagnosed IBC.  At that time, the
760433 - surgeon recalled not having enough time to perform examinations during
760434 - 2002 and 2003, ref SDS 9 XU75, when IBC was growing, e.g., CT test
760435 - report on 030710 recommending the doctor "correlate clinically" new
760436 - findings that were diagnosed a year later as IBC ref SDS 5 GJ69
760437 - Previously in 2002 and 2003, as proposed today, the doctor relied on
760438 - team care to notify of complications that require surgery. ref SDS 9
760439 - XU75  Later, on 041202 the attending physician in the Emergency Room
760440 - ordered examination by the surgeon, because the punch biopsy taken on
760441 - 040419 had not healed. ref SDS 15 AH9H  On 050107 the surgeon examined
760442 - the punch biopsy taken eight months earlier, and diagnosed relapse of
760443 - IBC which prevented surgery. ref SDS 17 IS5N  This suggests applying
760444 - team care for dual examination that cross-checks diagnoses to verify
760445 - accuracy rather than an excuse to avoid patient care because the other
760446 - doctor did not ask for an examination.  Team care should bring better
760447 - care not finger pointing.
760448 -
760449 -     [On 051103 study shows 34% of patients report experiencing medical
760450 -     mistakes due to communication gap, lack of coordination in team
760451 -     care where several doctors collaborate in providing care to a
760452 -     patient. ref SDS 50 ET68
760454 -  ..
760455 - The doctor said that follow up examination and monitoring of Millie's
760456 - treatment will be performed again in the oncology department, like
760457 - last year.  On 051007 the primary care physician in Oncology advised
760458 - that he did not need to schedule another examination with Millie.
760459 - ref SDS 37 JN4J  Today, the surgeon said she would contact the
760460 - oncologist and request follow up patient care.
760461 -
760462 -        [...see below, required follow up on DCIS in right breast to
760463 -        evaluate disease-free status. ref SDS 0 BA5G
760464 -
760465 -
760466 -
760467 -
7605 -

SUBJECTS
Relapse Testing CA 15-3 PET CT Imaging Testing for Disease-free Pati

7803 -
780401 -  ..
780402 - Relapse Focus of Treatment for Disease-free Patient after Surgery
780403 - Work Plan Testing Disease-free Status for Relapse CA 15-3 PET CT Scans
780404 -
780405 - Evaluation for relapse requires vigorous, and routine testing based on
780406 - Millie's history of relapse while off chemotherapy shown in the study
780407 - on 050812, ref SDS 23 UF4J, and in this case to recuperate from
780408 - surgery on 051021, ref SDS 44 0001, per Doctor Bailey's 2nd opinion
780409 - received on 050922. ref SDS 31 XD6U
780410 -
780411 -     [On 051121 primary care physician ordered bi-monthly CA 15-3
780412 -     testing, and scheduled PET scan testing beginning on 060115.
780413 -     ref SDS 51 FV6L
780415 -      ..
780416 -     [On 060217 PET scan test finds no evidence metastatic disease;
780417 -     doctor describes swelling left axilla as post op localized edema.
780418 -     ref SDS 56 T56K
780420 -  ..
780421 - The doctor said that Millie will have to be off systemic chemotherapy
780422 - treatment for 3 - 4 weeks in order for the surgical wound to heal.  If
780423 - IBC relapses within this period, exigent treatment will be required.
780424 -
780425 -     [On 051121, 5 weeks after surgery on 051021, primary care
780426 -     physician examined patient and found Millie is healing normally
780427 -     without complications. ref SDS 51 025H
780429 -  ..
780430 - No published guidance was cited nor submitted on treating secondary
780431 - IBC patients with mastectomy surgery.
780432 -
780433 -
780434 -
780435 -
7805 -

SUBJECTS
Status Change Retest Biopsy to Increase Treatment Options Meeting Do

8003 -
800401 -  ..
800402 - Status Change Retest Biopsy to Increase Treatment Options
800403 -
800404 - Millie asked the doctor about progress with restest the biopsy 040419
800405 - for status change to increase treatment options for the patient, as
800406 - discussed on 051022, ref SDS 45 NE9J
800408 -  ..
800409 - The biopsy received today on tissue from mastectomy surgery on 051021
800410 - reports finding DCIS which can be treated with hormonal therapy under
800411 - some circumstances, per below, ref SDS 0 BA6K, and this may add
800412 - urgency to testing for status change.
800414 -  ..
800415 - The doctor has still not received the report on retesting, discussed
800416 - originally on 050923. ref SDS 33 RX4I  She will notify the pathology
800417 - lab to check for filing error as a result of the biopsy slide returned
800418 - to Kaiser after use for a 2nd opinion, reported on 050913, ref SDS 28
800419 - NP7M, and completed on 050916. ref SDS 29 254S
800420 -
800421 -     [On 051121 primary care physician found that the Pathology
800422 -     Department has not reported results of retesting for status
800423 -     change; the doctor called the department to request expedited
800424 -     retesting. ref SDS 51 TI4J
800425 -
800426 -
800427 -
800428 -
8005 -

SUBJECTS
Pulmonary Emboli Treatment Coumadin Resumed Requires Work Up Hyperco

8403 -
840401 -  ..
840402 - Pulmonary Emboli Treatment Coumadin Resumed Requires Work Up
840403 -
840404 - Follow up ref SDS 48 PO7J.
840405 -
840406 - Pulmonary emboli treatment with Coumadin was resumed by the doctor
840407 - yesterday, based on a call from Gloria in the Anticoagulant Clinic in
840408 - the Kaiser hospital located in Martinez. ref SDS 48 PO85
840409 -
840410 -     [On 051121 primary care physician ended Coumadin treatment for
840411 -     pulmonary emboli, and called the Anticoagulant Clinic in Martinez
840412 -     to confirm this change. ref SDS 51 RZ4I
840414 -  ..
840415 - Hypercoagulable state work up recommended on 050922 by Doctor Bailey
840416 - in a 2nd opinion citing patient history, and related family medical
840417 - history, ref SDS 31 XD9X, surgeon wants Millie to ask the oncologist
840418 - to address this action item.
840419 -
840420 -     [On 051121 primary care physician determined work up on
840421 -     hypercoagulable state not required. ref SDS 51 GW7G
840422 -
840423 -
840424 -
840425 -
840426 -
840427 -
8405 -

SUBJECTS
Port Catheter Requires Flush Maintenance While Off Chemotherapy

8503 -
850401 -  ..
850402 - Port Catheter Requires Flush Maintenance While Off Chemotherapy
850403 -
850404 - The doctor suggested that Millie coordinate with the primary care
850405 - physician for scheduling port catheter flush, based on period of next
850406 - chemotherapy treatment. ref SDS 44 QW3M
850407 -
850408 -     [On 051121 primary care physician submitted a schedule to Millie
850409 -     for getting the port flushed on 051202. ref SDS 51 SH5N
850410 -
850411 -
850412 -
850413 -
850414 -
8505 -

SUBJECTS
Disability Leave Entitlement Recover from Mastectomy Surgery Authori

8903 -
890401 -  ..
890402 - Disability Leave Entitlement Authorized by Surgeon
890403 -
890404 - Follow up ref SDS 37 J29L, ref SDS 32 0001.
890405 -
890406 - Medical leave disability eligibility filing; N&P wants notice
890407 - from the attending physician on the length and justification of
890408 - entitlement.
890410 -  ..
890411 - The doctor prepared documents authorizing 6 weeks medical
890412 - leave.
890413 -
890414 -
890416 -  ..
8905 -
8906 -
8907 - 1533
8908 -
890801 - After meeting with the surgeon, Millie went to the Business Office on
890802 - the first floor and filed the documents for disability leave.
890803 -
890804 -
890805 -
890806 -
890807 -
890808 -
890809 -
890810 -
8909 -

SUBJECTS
Biopsy Received Pathology Findings for Biopsies Taken on 051012 to D
Biopsy IBC No Evidence Metastatic Disease Local Control Disease-free

9604 -
960501 -  ..
960502 - Biopsies Determine Complete Response to Treatment Local Disease
960503 -
960504 - Follow up ref SDS 44 L13H, ref SDS 41 DG6J.
960505 -
960506 - Millie asked the doctor about the pathology report on the biopsy of
960507 - tissue from the operation on 051021, ref SDS 44 EG5L, to supplement
960508 - the report on the test biopsies taken on 051012, and received on
960509 - 051021 showing no evidence of cancer. ref SDS 44 LH6O
960511 -  ..
960512 - The doctor said the report is favorable.  She gave Millie five (5)
960513 - sheets of paper that were a bit mixed up.  Millie read the first
960514 - document in the stack labeled page 3 of 8, which was actually the end
960515 - of the report showing diagnosis that says no inflammatory carcinoma
960516 - was found. ref SDS 0 616P
960518 -  ..
960519 - Millie was very pleased with the report submitted today.
960521 -  ..
960522 - Subsequent review following the meeting shows the sheets of paper
960523 - received from the doctor are in reverse order, and for some reason
960524 - there is a page from the biopsy on 051012.
960526 -  ..
960527 - We need the actual report for the biopsy on 051021 in order to
960528 - complete the record.
960529 -
960530 -     [On 051121 received corrected copy of biopsy from the primary care
960531 -     physician. ref SDS 51 UF4L
960533 -  ..
960534 - Piecing together representations in the papers shows the following...
960536 -     ..
960539 -     ..
960540 -    Patient
960544 -     ..
960545 -    Personal Physician:
960548 -     ..
960549 -    68/F Radiology Report               Exam  1 of 1
960551 -     ..
960552 -    Clin History
960553 -
960556 -     ..
960557 -    History
960558 -
960559 -        None given.
960561 -  ..
960562 - Why no patient history presented, since this is included with other
960563 - pathology reports (see listing on 051007, ref SDS 37 XU7N), and
960564 - provides critical context, e.g., biopsy on 040419 and received on
960565 - 040517 identified inflammatory carcinoma of the left breast,
960566 - ref SDS 11 7D6F; and test biopsies performed on 051012 and then
960567 - reported on 051021 showed no evidence of IBC at the breast perimeter.
960568 - ref SDS 44 LH6O
960570 -  ..
960571 - Biopsy report diagnosis continues...
960572 -
960573 -    Gross Desc
960574 -
960575 -        Received is a simple mastectomy specimen in its entirety 15.5 x
960576 -        13.3 cm.  It has a greatest depth of 6 cm.  There is an everted
960577 -        pink nipple that measures 1.3 cm.  A short suture for superior
960578 -        and a long suture for lateral.  The deep margin of the specimen
960579 -        reveals unremarkable fibrofatty tissue.  Serial 0.3 cm sections
960580 -        through the breast do not show evidence of tumor.  On the
960581 -        medial aspect of the breast there is a previous incisional scar
960582 -        that measures 2.5 cm.  Cut surface through the breast below
960583 -        this does not show tumor or blood clot.  Small areas of
960584 -        punctate hemorrage is identified which is submitted as 5.
960585 -        Nipple submitted as 1;skin of the breast as 2 through 4;
960586 -        previous biopsy site 5; lateral breast 6; outer upper quadrant
960587 -        7; outer lower quadrant 8; upper inner quadrant as 9; upper
960588 -        lower quadrant as 10.
960590 -     ..
960591 -    SP Final Report
960593 -     ..
960594 -    Specimen
960595 -
960596 -        Left breast tissue
960597 -        Breast NOS
960599 -     ..
960600 -    Diagnosis
960601 -
960602 -        1.  Granulation tissue with inflammation and necrosis of
960603 -            previous biopsy site.
960604 -
960605 -
960606 -
9607 -

SUBJECTS
Ductal Carcinoma In Situ (DCIS) Diagnosed Nipple Left Shown by Patho

9803 -
980401 -             ..
980402 -            Ductal Carcinoma in Situ (DCIS) diagnosed...
980403 -
980404 -        2.  Nipple with underlying dilated lactiferous ducts with
980405 -            markedly atypical cells within the lumen consistent with
980406 -            ductal carcinoma in situ.
980408 -  ..
980409 - Finding DCIS in mastectomy tissue aligns with pathology for original
980410 - surgery on 020312, which was submitted to the patient on 020321.
980411 - ref SDS 2 9N4J
980413 -  ..
980414 - DCIS may explain why CA 15-3 has remained elevated even though there
980415 - is no evidence of disease in image tests.
980417 -  ..
980418 - The doctor summarized as pre-cancerous "funny stuff" this part of the
980419 - biopsy report showing "markedly atypical cells...consistent with
980420 - ductal carcinoma in situ (DCIS). see context above. ref SDS 0 JN3L
980421 - The doctor's presentation today omitting the finding of DCIS fits the
980422 - model of work on 040429 when cancer was found in a biopsy on 040419,
980423 - and inflammatory carcinoma (IBC) was not explained nor that IBC is an
980424 - aggressive form of breast cancer. ref SDS 10 C155  Similarly, on
980425 - 040517 the primary care physician handed Millie the pathology report
980426 - and did not explain findings of IBC. ref SDS 11 6T5G
980427 -
980428 -        [On 051127 CA 15-3 drops from 45 down to 34, a dramatic change
980429 -        attributed to mastectomy removal of DCIS and possibly
980430 -        microscopic IBC, metastatic disease in the left breast not
980431 -        detected by PET and CT tests. ref SDS 51 GJ5M
980432 -
980433 -
980435 -  ..
980436 - DCIS was researched independently, ref SDS 11 YN3L, after meeting with
980437 - the surgeon today...
980439 -  ..
980440 - Research at...
980441 -
980442 -              http://www.cancerbacup.org.uk/Cancertype/Breast/DCISLCIS/DCIS
980443 -
980444 -        Cancerbackup
980445 -
980446 - ...on the Internet describes...
980447 -
980448 -            ...DCIS...cells lining the milk ducts...are cancerous, but
980449 -            stay contained within the ducts without growing through
980450 -            into the surrounding breast tissue.  DCIS may affect just
980451 -            one area of the breast but can be more widespread and
980452 -            affect different areas at the same time.  Sometimes DCIS
980453 -            may be described as pre-cancerous, pre-invasive,
980454 -            non-invasive or intraductal cancer.
980456 -             ..
980457 -            There are three grades of DCIS - low, intermediate and
980458 -            high.  The grade refers to how abnormal the cells look
980459 -            under the microscope and gives an idea of how quickly the
980460 -            cells may develop into an invasive cancer (or how likely it
980461 -            is that the DCIS will come back after surgery)  Low-grade
980462 -            DCIS has the lowest risk of developing into an invasive
980463 -            cancer and high-grade the greatest risk.
980465 -  ..
980466 - The biopsy report does not present the grade of DCIS, ref SDS 0 615K,
980467 - which influences treatment protocols with radiation for high grade
980468 - DCIS.  Why no explanation of how the cells look under the microscope
980469 - for assessing risk?
980470 -
980471 -     [On 051121 primary care physician submitted biopsy and considered
980472 -     findings of DCSI; no further testing was ordered, and the patient
980473 -     was found NED. ref SDS 51 KV9G
980475 -  ..
980476 - The doctor seemed to describe the biopsy diagnosis as "pre-cancerous,"
980477 - but this is not set out in the actual report.
980479 -  ..
980480 - Cancerbackup research on Internet continues...
980481 -
980482 -            ...women...at a higher risk [for contracting DCIS]...have
980483 -            never had any children, or...had them late in life, women
980484 -            who started their periods at a young age or who had a late
980485 -            menopause, and women who have a strong family history of
980486 -            breast cancer.
980488 -  ..
980489 - Millie has none of these risk factors.
980490 -
980492 -  ..
980493 - DCIS Risk Right Breast Not Evident from Testing Except Biopsy
980494 - Complex Diagnosis No Evidence DCIS Until Biopsy on Mastectomy Surgery
980495 -
980496 - The surgeon feels Millie's patient profile is very complex, involving
980497 - several relapses following lumpectomy, secondary IBC difficult to
980498 - diagnose, surgery delayed by speading IBC relapse, wide mastectomy
980499 - surgery, prolonged symptoms pulmonary emboli, lymphadenapathy in left
980500 - and right axillia, and left supraclavicular, and now DCIS in the left
980501 - breast.
980502 -
980503 -        [On 061020 primary care physician feels patient profile has
980504 -        too many issues for a 5-year medical case of secondary
980505 -        inflammatory breast cancer (IBC), cellulitis, lymphedema,
980506 -        pulmonary embolism, broken finger. ref SDS 65 MO4K
980508 -  ..
980509 - DCIS was not reported on the PET scan test received on 051007, nor on
980510 - any prior test. ref SDS 37 AG6G  Research says that DCIS can be seen
980511 - on mammograms, as tiny specs of calcium.  Millie's mammogram test on
980512 - 050922 reported findings on 051019 that show no evidence of DCIS, nor
980513 - cancer of any kind. ref SDS 43 DY8R  This is the second consecutive
980514 - mammogram test that reported no findings of cancer, and subsequent
980515 - investigation showed this was a mistake. see report on 020312.
980516 - ref SDS 1 YV3O  This record does not seem to support recommendations
980517 - on 050907 for Millie to get another mammogram test. ref SDS 25 AE6W
980518 - Doctor Bailey also suggested another mammogram test, called out in a
980519 - 2nd opinion received on 050922. ref SDS 31 XD7U
980521 -  ..
980522 - Another source on the Internet says DCIS can be detected with biopsy
980523 - tests using Fine Needle Aspiration Biopsy (FNAB), and also by Core
980524 - Needle Biopsy (CNB), used previously to detect cancer in the neck on
980525 - 040303, ref SDS 6 Y171, and then later to detect IBC in the left
980526 - breast on 040419. ref SDS 9 XU52  Why then doesn't DCIS jump out from
980527 - the general biopsy, rather than solely from the nipple tissue?  Does
980528 - this mean that, but for the total surgical removal of the left breast,
980529 - the type of punch biopsy that discovered IBC on 040419, would not have
980530 - identified DCIS that resides in this case evidently only in nipple
980531 - tissue?
980533 -  ..
980534 - Actually, the original biopsy of tissue from lumpectomy surgery on
980535 - 020312 yielded pathology report on 020321 that reported finding ductal
980536 - carcinoma in situ. ref SDS 2 9N4J
980538 -  ..
980539 - The biopsy finding of "atypical cells" consistent with DCIS may align
980540 - with the primary care physician's worry on 051007 about microscopic
980541 - cancer calls causing relapse. ref SDS 37 I482  Fortunately in this
980542 - case, the biopsy test occasioned by mastectomy surgery discovered
980543 - these cells in tissue now removed.
980545 -  ..
980546 - What about the right breast?  Does the biopsy report that found cancer
980547 - was missed by PET and mammogram testing on the left breast require
980548 - investigating for cancer missed in the right breast?  Could DCIS
980549 - missed in the right breast by testing be causing elevated CA 15-3 and
980550 - lymphadenopathy in the right axillary, cited on 051007, ref SDS 37
980551 - OG5J, since research indicates DCIS typically does not spread to lymph
980552 - nodes, but sometimes does?  How does the biopsy finding of DCIS affect
980553 - the conclusion of disease free status, per above? ref SDS 0 M58G
980554 -
980555 -     [On 051121 primary care physician submitted biopsy and considered
980556 -     findings of DCSI; no further testing was ordered, and the patient
980557 -     was found NED. ref SDS 51 KV9G
980559 -  ..
980560 - DCIS is commonly treated with surgery; research shows no discussion of
980561 - systemic treatment with chemotherapy, which may account for finding no
980562 - IBC with the presence of DCIS cells.
980564 -  ..
980565 - Tamoxifen is a common hormonal therapy for osteogen-receptor positive
980566 - DCIS.  This may relate to pending retest of biopsy on 040419 for
980567 - status change, discussed below.
980568 -
980569 -
980570 -
980571 -
9806 -

SUBJECTS
Biopsy IBC No Evidence Metastatic Disease Local Control Disease-free

A003 -
A00401 -  ..
A00402 - No Evidence of Disease NED Inflammatory Carcinoma
A00403 - Clear Margins Implied by Biopsy Pathology Report Diagnosis
A00404 - Inflammatory Carcinoma No Evidence of Disease in Left Breast
A00405 -
A00406 - Biopsy report diagnosis concludes...
A00407 -
A00408 -        3.  Dermal lymphatics in nipple and skin sections - no
A00409 -            evidence of inflammatory carcinoma.
A00410 -
A00411 -                [...see also gross description. ref SDS 0 QX69
A00413 -             ..
A00414 -        4.  Random sections of breast - unremarkable. (Left breast
A00415 -            simple mastectomy)
A00417 -     ..
A00418 -    051026/jkb
A00419 -    LL Brewer, MD
A00421 -  ..
A00422 - The surgeon presented this report as showing clear margins, which does
A00423 - not require reexcision, per above. ref SDS 0 JN3L
A00425 -  ..
A00426 - There is no mention of "clear margins" but this may be implied by the
A00427 - findings.
A00428 -
A00429 -     [On 051121 received biopsy report from primary care physician;
A00430 -     shows no mention of clear margins. ref SDS 51 UF4L
A00431 -
A00432 -
A00433 -
A00434 -
A00435 -
A00436 -
A00437 -
A00438 -
A00439 -
A00440 -
A00441 -
A005 -