Friday, February 20, 2009


Let's just get it all out in the title.  That's what I am talking about tonight.  Breasts.  Some days I feel like they exist as a nidus for cancer.  We see so many breasts, in pathology.  Yesterday, my partner ordered nine special hormone studies.  That means he had nine breast cancers, in one day.  And that's just one guy -  Surgicals are split among many pathologists.  Come to think of it, we see a lot of uteri as well.  Most are benign, but there's a lot of cancer there, too.  Penises, testicles, not so much - both are rare specimens.  Sure, there's a lot of prostate cancer, but the prostate is internal, and doesn't carry quite as much weight, when you are naming male and female private parts.  There seems to be an imbalance, in the cancer category.  We females are always getting shafted.

Most breast cancer patients are in their 50's and 60's, but I swear they are getting younger and younger.  40 is not rare at all.  30 is becoming more and more common.  The first time I saw an ugly breast cancer in a 20-something, I was shocked, but now I know - it happens.  Some days it's enough to make you slam your door in complete paranoia and perform a self-breast exam.

The other day I was reading the gross dictation on one of my breast cancer specimens.  It was mid-morning, about 2 hours after my first of two coffees for the day.  I was skimming along, searching for the important information needed for staging - size of lesion, distance from margins, etc.  I read about the size of the breast, the size of the areola, and all of the sudden I got to the nipple.  "The nipple appears erect."  

I felt like someone had slipped pornography into my gross dictation.  Erect?  I read it again, thinking I must have made some egregious mental error.  Nope, it was still there.  I immediately thought, "What disgusting boy gross tech described the nipple as erect?"  I scanned down to the initials at the end of the dictation to find out.  There were two sets of initials, not uncommon in a double mastectomy specimen - if there are two breasts, they are often tag-teamed.  Both sets of initials were female.  I mentally decided which female was more likely to have described the nipple of a detached, still-warm slab of breast on a cutting board as erect.  Which probably means it was the other one.  Or maybe it was a typo on the transcriptionist's part (also all female).  Possibly, it was an intentional gaffe; a mischievous trick meant to catch my attention, or lack thereof.  I decided it wasn't really important to chase down the culprit, I would just strike it from the dictation before I released the report.

As I continued to work on the case, I grew paranoid.  What if erect nipples had been peppering my gross dictations for months, and I was just now noticing it for the first time?  How many of my breast reports were out there, with my medical signature on them, describing erect nipples?  I decided to take an informal poll of a select group of partners.

First I showed one of my female partners.  "Read this."  She pulled out her glasses.  I had to point to the right spot, she wasn't getting to it fast enough.  When she read the sentence she looked up in alarm.  "Oh my god!  It sounds like the breast is stimulated!  That is awful!  Who grossed that breast?"  She assured me that she had never seen a nipple described as erect, and since she is one of the most amazingly OCD in a good way pathologists I have ever met, I trusted her, and was relieved.

I went to another female partner.  She was equally shocked.  Good.  I decided then that I needed one male opinion, so I went to my colleague that I have known for almost 12 years.  We went to med school together, but I didn't really know him well because he spent most of his time on the golf course.  We got to be friends during residency, but our relationship was always laced with competition, since we were in the same class, and gunning for the same jobs.  It has been nice to experience that edginess melt away into easy camaraderie over the last couple of years, although I am still jealous of his supreme confidence.  I learned a lot from watching him, during residency, shake off the criticisms and berating stemming from attending stress and bad moods like water off a duck's back.  Rather than sulk and get defensive, he would have them laughing in short order.  He is the one male in my group I feel comfortable enough with, based on our long history, to broach the subject of erect nipples without turning an irreversible shade of crimson that would necessitate an excuse for a quick exit.

"Of course, I have seen that before.  Erect nipple.  Isn't that the opposite of inverted?"

Go figure.  He has seen everything before.  It is important, when examining the nipple, to note if it is inverted.  Breast cancers are hard, stellate, arachnoid masses, that sometimes traverse ducts and fix and grab as they go.  If their tentacles crawl around in the nipple ducts, the traction can pull a nipple inward, retracting or inverting it.  So it is necessary to note if the nipple is inverted.  Importantly, before I alarm the reader, inverted nipples are common, and most are not the result of cancerous fixation.  Breast cancer can also infiltrate the dermal lymphatics - the lymph channels of the skin -- and create a similar pull on the skin that has a catchy descriptive term - peau d'orange.  

I told Dr. Woods that I had never seen a nipple described as erect.  In my world, erect is not the opposite of inverted.  And I had never really mentioned the nipple, during my grossing days, unless it was inverted or retracted.  He said, "Oh sure, haven't you ever described the penis as erect?  You know, those guys with penile implants?"  

"What?  You had a penis removed for a penile implant?"  I had only had two penises as specimens, that I could remember, and both were partials for squamous cell carcinoma.  "No!  Autopsies.  Those old guys at the VA."  Oh.  Duh.  Well, if I had ever seen one of those, I don't remember noticing.

I decided to quit there.  I had enough information.  I have been reading my gross dictations much more closely since then, and have not noticed any more pornography.  I have another funny breast story, but I am tired.  It was a rough week.  I had way too many interstitial lungs - fascinating but very mentally challenging cases.  Happy Friday!!!  

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