Well here goes--5 weeks out I finally have the final report from the autopsy. Just to remind you, about a month before Sally died, we had the results of the CT scan that did not show any tumor in the abdomen including the liver. The chemotherapy had just been stopped after six cycles and Sally was on the road to recovery, we thought. Well, we all know that didn't happen and she deteriorated rapidly with worsening liver function and other problems. Below are the main results of the autopsy.
LIVER: There was massive involvement of the liver with metastatic breast cancer. This was not in the form of masses but there were infiltrating bands and sheets of tumor that fooled CT scan into thinking it was not there. Surrounding the tumor was fibrosis. This is what caused the main blood vessel to the liver to be obstructed and resulted in the dilated blood vessels that ruptured and bled causing Sally's death. The pathologist estimated that 80 to 90 percent of the liver was replaced by tumor with very little remaining normal liver.
ADRENAL GLANDS: There was bilateral involvement of the adrenal glands with metastatic breast cancer. Again, the CT scan, which is usually good at imaging the adrenals, did not detect this. At the end of her life, Sally had a problem with her blood potassium concentration. The high potassium that she had may be the result of adrenal insufficiency caused by the tumor because of lack of adrenal steroids.
STOMACH: There was metastatic carcinoma growing in the wall of the stomach. This was another infiltration without masses so was invisible to the CT scan.
KIDNEYS: Both kidneys have multiple foci of metastatic carcinoma
UTERUS: The myometrium (the muscular wall of the uterus) had extensive involvement with metastatic breast cancer.
BRAIN: There was metastatic invasive lobular carcinoma of the breast throughout the brain including the meninges (brain covering), the cerebral cortex, the cerebellar cortex, the posterior lobe of the pituitary gland and the pineal gland. The posterior pituitary makes a hormone that controls body water. Sally had a very low serum sodium toward the end and this may be the result of water retention with dilution of the sodium as a result of the tumor in this part of the brain. Thank God that Sally had no symptoms or signs of brain dysfunction--but had she lived, she would have undoubtedly developed them.
So. . . I'm glad that we have this information. Sally's tumor was essentially undetectable to the imaging used in modern medicine. At the start it escaped detection by mammography, and was only detected because an equivocal ultrasound led to a biopsy. At the time of detection it had already spread to the lymph nodes and bones--and very likely even farther. The tumor was thought to be one that might give Sally many years of life and could be controlled. There were estrogen and progesterone receptors that "fed" the tumor. The therapy of choice recommended by MD Anderson and by Dr. Conlon was to block estrogen production and thereby "starve" the tumor. Sally did well for about a year on this estrogen blocker therapy, but after a year this terrible tumor escaped this therapy. Last fall Sally was very sick as those of you know who have been following this blog. A trial of a standard breast cancer chemotherapy, Taxotere, was begun and Sally responded. She started to feel better and we had a good Christmas and Easter. But clearly this horrible tumor was still growing in ways that eluded detection and very likely nothing much was going to stop it. The final thing that led to Sally's demise was the consequences of the liver involvement, but if it hadn't been that, it could have been something worse, like neurologic problems.
Everyone knows someone with breast cancer and for many early detection and therapy results in a cure or long term survival. Sally was unusual, not only in type of breast cancer (invasive lobular makes up only 10% of tumors) but also in the course of this tumor. The literature is really not helpful since this type of breast cancer is lumped in with the more common type of breast cancer that forms masses and therefore is more easily detected and imaged. I hope that someone, sometime will realize the uniqueness of the lobular carcinoma and study it separately from the rest of breast cancer.
