Ten days after my surgery I had a postoperative appointment with my surgical oncologist (My teeny, tiny, supercharged superhero. I stan!). She shared the results of my pathology report with me. She was enthusiastic about them. Me, not so much.

Everything that was removed during surgery was measured and tested. A summary–10 pages of technobabble–comprised the pathology report.

There was so much hanging on the report. After completing chemotherapy (but before surgery) I had asked my medical oncologist for my prognosis. It’s something I hadn’t even been able to say out loud until then. It was too scary and I was too afraid of what her response might be.

What are my odds? By pursuing the most aggressive treatment possible, how much had I lowered the likelihood of a recurrence? She said that she wasn’t comfortable saying anything until the pathology report was finalized. So, to quote Owen Wilson in Armageddon once again, “so the scariest environment imaginable….” I’ll just cozy up with that idea, pull my fears in real close, and sit in hypervigillant terror chamber until the report comes in. Super.

I was naively holding on to the idea that the pathology report would show that there were no active (alive) cancer cells remaining. I had no reason to believe this. If anything, I had reason not to believe this. But somehow I had arbitrarily separated two concepts: I had told myself that because the tumor had decreased in size it surely wasn’t growing any more. The chemo must have not only stopped it from growing but also killed it completely. Not true.

The report confirmed what my surgeon had told me immediately after surgery – all the cancer that had been identified when I was diagnosed was successfully removed. (Unfortunately, some cancer that hadn’t been identified when I was diagnosed was also found, which is why I ended up needing an axillary dissection). Here are the cliff notes:

• My margins were clear.

• Chemo shrank my tumor a little, from roughly 5 cm (as measured via an MRI), to 4 cm.

• Chemo shrank the (identified and biopsied) lymph node from 2.6 x 1.5 cm to 2.3 x 1.1 cm.

• The cellular makeup of my tumor changed from being 60% Estrogen Receptor positive and 50% Progesterone Receptor positive to 75% ER + and 0% PR +. This change is likely because the surgical pathology was more comprehensive (a biopsy only tests a small portion of a tumor, whereas the entire tumor was removed and tested after surgery. And, theoretically, it’s possible that the chemo was effective at killing any PR+ cells.).

• Out of 5 sentinel lymph nodes, 2 were positive for cancer (1 I knew about, 1 I didn’t).

• Out of the remaining 13 lymph nodes that were removed, 0 were positive for cancer.

• Of the cancerous cells found, removed, and tested, 30% were still viable. This means I did not have a complete pathological response to chemo.

Some Notes

BreastCancer.org has the best guide I’ve found for understanding surgical pathology reports. It’s no substitute for discussions with your doctor, but it’s great for simplifying complex concepts and and terms.

Because of the unique biology of my cancer, chemotherapy doesn’t usually do too much. I was shocked to hear that it had any impact at all. Invasive Lobular Carcinoma (ILC) doesn’t form a lump and here’s why: it usually lacks a protein called E-cadherin which holds cells together. ILCs grow as linear strands of cells rather than as compact masses.

This means that it would have been unlikely that the total length of my tumor would change dramatically. It’s more likely that cancer cells throughout it did, but that didn’t significantly affect its overall shape or size.

Tumor Size

Doctors measure cancers in centimeters. The size of the cancer is one of the factors that determines the stage and treatment of breast cancer. Size doesn’t tell the whole story. All of the cancer’s characteristics are important. A small cancer can be very fast-growing while a larger cancer may be slow-growing, or it could be the other way around.

Surgical Margins

During surgery, a surgeon tries to remove all of the cancer plus a little extra area of tissue around the tumor, called a margin. This is to make completely sure that all of the cancer is removed. Margins are described in three ways:

Negative/Clear: No cancer cells can be seen at the outer edge. Usually, no more surgery is needed.

Positive: Cancer cells come right out to the edge of the tissue. More surgery is usually needed to remove any remaining cancer cells.

Close: Cancer cells are close to the edge of the tissue, but not right at the edge. More surgery may be needed.

Breast Cancer Hormone Receptors

Breast cancers that are ER and/or PR positive tend to respond well to hormone therapy. Hormone therapy is medicine that reduces the amount of estrogen in your body or that blocks estrogen from receptors. Higher numbers of hormone receptors can often predict a particularly good response to hormonal therapy. Hormone receptors are proteins and like all proteins, their production is controlled by genes.

Genes contain the recipes for the various proteins a cell needs to stay healthy and function normally. Some genes and the proteins they make can influence how a breast cancer behaves and how it might respond to a specific treatment. I knew from my initial genetic testing that I didn’t have any mutations or abnormalities (aka a mistake in the genetic recipe).

I also knew from my initial biopsy that my breast cancer is HER2 negative. The HER2 gene is responsible for making HER2 proteins. These proteins are receptors on breast cells. Under normal circumstances, HER2 receptors help control how a breast cell grows, divides, and repairs itself. But in about 25% of breast cancers, the HER2 gene can become abnormal and make too many copies of itself (amplification of the HER2 gene). Amplified HER2 genes tell breast cells to make too many receptors (overexpression of the HER2 protein). When this happens, the overexpressed HER2 receptors shout at (rather than talk to) the breast cells to grow and divide in an uncontrolled way. This can lead to the development of breast cancer.

HER2 positive breast cancers tend to grow faster and are more likely to spread and come back when compared with HER2 negative breast cancers. But HER2 positive breast cancers can respond to some phenomenally successful, targeted treatments that are designed to work against HER2 positive cancer cells.