I used to think that being a radiologist—a doctor whose specialty is reading medical images of various sorts and administering radiation therapy for cancer—was a fairly straightforward medical career. Regular hours. Spend your days reading x-rays and zapping cancers with ray guns. Lots of “procedures,” the main way to make money in our goofy medical “system” that rewards doing stuff more than holistic care. How wrong I was.
In the last two months, my breasts—the left first, and now the right—have gotten all sorts of attention from quite a few radiologists: the radiologist who read my first mammogram this year and ordered a follow-up mammo and then the first biopsy; the radiologist who did that biopsy and operated a high-tech targeting system with aplomb and compassion; the radiologist who directed and read my first MRI; and, this week, the radiologist who did an ultrasound and a fine needle biopsy of my right breast; and finally, the radiologist who directed a team of six to do an MRI-guided core biopsy of yet another part of my right breast.
That list alone is dizzying, now consider all the different ways of “seeing” involved:
• Mammograms use low-dose x-rays to create an image. They’re good at detecting densities of tissue and distances. The more dense the tissue the lighter the image, that’s why bones show up white on x-rays, and why the “micro-calcifications” that tipped off my cancer looked like grains of salt on my first mammograms. For a mammo, my breast is squished like a pancake, to even out the thickness of the tissue so that radiologist has a better chance of seeing everything, a better chance of catching cancer that’s trying to hide in the background.
• As described at length in an earlier post, magnetic resonance imaging (MRI) systems use magnets, radio waves, and contrast dye to create an image. For an MRI, my breast is slightly compressed in a cube-shaped plastic receptacle, so that the computer system can image my breast in “slices” at any angle. MRIs are terrific at highlighting the circulatory system and at creating very detailed images of tissue. Because they’re so detailed, they often lead to “false positives,” i.e. highlighting something that looks like it might be cancer but turns out not to be cancer. For all our sophistication and technology, the only sure way to tell cancer from not-cancer is to cut it out and look at in under a microscope. More on that in a minute.
• Ultrasound machines use sound waves to create an image. Like a battleship or a dolphin or a bat, the ultrasound machine sends out pulses of high-frequency sound waves. When the sound waves hit an object, some of them get bounced back, creating an “echo.” The machine measures these sound wave echoes—how fast did they come back, how strong are they, what frequency—to create an image on a monitor that looks like a computer screen. Ultrasounds can create a real-time image of what’s going on inside your body; some kinds of ultrasounds can even create 3D images. Ultrasound waves pass easily through soft tissue and fluids, so they’re excellent at detecting liquid and movement. They can literally reveal your blood pulsing through your veins. I’ll never forget seeing my daughter’s heartbeat on an ultrasound when I was just seven weeks pregnant. In the case of a breast ultrasound, I lie on my back, and my breast kind of flops naturally to the side.
Think about all this: Some images the radiologist sees are essentially flat, in two dimensions. Some flat images are on an horizontal angle, others can be from any angle from horizontal to vertical. Some have depth, in three dimensions. Some are static, a snapshot from one moment in time. Others are in real-time, like a video. It’s as if you have a picture of a flower in the regular light spectrum, another picture of the flower in the ultraviolet spectrum and then a time-elapsed film of the flower morphing from bud to bloom. Put them all together, and voila, reality.
A couple days ago, I lie on an exam table in an ultrasound procedure room and a beautiful, slim radiologist in a summer shift comes in to mark my breast “R,” just in case she forgets which breast we are imaging and biopsying this day. (Operations do get done on the wrong side or the wrong organ occasionally, so I guess the NYU lawyers insist on this marking. I still have a faint “R” there, like “prime” stamp on beef.) After she explains how the “fine needle biopsy” will go, I ask her how she is able to put all the images and methods of seeing together. I ask if, over the course of her training, she has learned a way to visualize the three-dimensional architecture and physiology of my breast from all those partial snapshots and angles and methods.
“That’s very perceptive,” the radiologist says. “That’s exactly what I’m doing.” It’s embarrassing how much pleasure I get from that small bit of praise, an acknowlegement, that I, a layperson, can have an inkling of what doctors know.
She comes back a few minutes later to give my right breast a shot of local anesthetic. She squirts a little bit of gel onto a hand-held ultrasound “transducer,” a column-shaped device that sends out the sound waves and measures the waves that come back. The gel helps transmit the sound waves and cuts out the static that might be created from any bit of air between my skin and the transducer.
In a moment, the interior of my right breast appears on the monitor: the lobules that stored milk when I was nursing, the ducts that delivered it nipple-ward, the deposits of fat, the nerves and blood vessels. As she moves the transducer, my tissue moves, the image on the monitor moves. How can she make sense of that, I wonder. It seems like trying to grab hold of a lava lamp.
But she does make sense of the undulating image. She finds what she’s looking for, that “good mass,” the nurse was talking about when me made this appointment for me. I think they suspect it’s just fibrous tissue, but I still haven’t seen the radiology report so I’m not absolutely sure. The doctor takes a fine needle and pushes it toward the mass. I close my eyes. If you have Valium, a local anesthetic and you don’t look, you can tolerate needles being pushed into your breasts. She pushes the needle in three times and draws out three samples of cells from the suspicious mass. She hands them to another beautiful doctor. Are there any homely doctors in this cancer center? This second doctor is a pathologist who smears the cells on slides in a canvas holder just like the one that held the slides when I first got a look at my cancer, just before my first NYU appointment.
The pathologist leaves the room to dye the slides and look at my cells under a microscope.
Ten minutes later, the radiologist comes back, and tells me the pathologist says the cells are benign, not cancer. She asks me into her office to explain the “finding” that she and the pathologist have agreed upon. Long story short, they were pretty sure the mass wasn’t cancer in the first place but they needed to check. They took three samples. None turned out to be cancerous. So this red flag has disappeared, for now. It doesn’t mean that it couldn’t come up again, she says, and it doesn’t mean the mass couldn’t grow. But then, she says, sometimes benign masses grow. Don’t freak out if it’s larger later. Or, sometimes, they turn into cancer. They didn’t cut out the entire mass, so this diagnosis is not 100 percent for sure. But the radiologist says that she and the pathologist think the diagnosis is reasonable, that is, most likely correct. It should be checked again in six months, she says. She hands me an order for that ultrasound appointment.
In breast cancer, as in larger life, there are no guarantees. And, medicine, like larger life, is more art than we usually want to admit.
Next day, another radiologist, another biopsy. This time, it’s guided by an MRI machine. This time, it’s not an intimate gathering of patient, a nurse and a couple doctors, but a full medical party: Radiology professor or “attending,” his student, or “fellow,” my favorite nurse, three MRI “technologists.” (Did you know you could get a BA in MRI imaging? You can.) This time, they won’t use a fine needle but a “core needle” that removes little columns of tissue from the suspicious area. They do this when there’s no “mass,” when the area is too small, or too unclear, or as in my case, the possible cancer looks like little grains of sand on the radiology image.
Again, I haven’t yet seen the report that ordered all these tests, but I’m guessing they’re going to take cores from around the place where they saw “microcalcifications,” little dots of calcium that can be pushed out of breast ducts, sometimes by narrowing of the ducts and normal aging, sometimes by cancer. The original mammo showed some of these in my right breast, but I guess they didn’t seem as suspicious as the ones on the left. Now that I’ve got cancer for sure on the left, they’re checking everything.
As before, I get screened for any metal that might turn into a projectile by the MRI magnet. I get an IV for the contrast dye. I lie down on the special exam table and suspend my right breast into the special receptacle.
This time, they’re not focusing on my left breast, so it’s pushed up a little, out of the way. Once the right breast is hanging down properly, the technologist takes a wall of plastic with a squares superimposed on it and uses it to squish my breast into a targeting grid, vertical, like the board of a “Battleship” game. The gaggle of professionals comes in, checks everything is correct. Leaves.
Into the MRI I go for a baseline scan. The auto-injector pushes the gadolinium contrast dye into my IV halfway through. The team analyzes the images. Back out I come.
While I lay there, face down, the docs discuss targeting, decide the area is most accessible from the left. They going to shoot the needle in under the breast that’s pushed out of the way. They pull out one square of the targeting grid and replace it with a plastic piece that has nine little holes. This gives them nine options for shooting the needles in.
They give me a surface anesthetic injection, then a deeper one. I suck in my breath a bit because it pinches a little. The radiology attending tells his student to be generous with the lidocaine. I love the attending.
One of the technologists holds my right hand and puts her other hand on my back, to both comfort me and to keep me from moving. If you move during an MRI, you mess the whole thing up. My eyebrows and my nose start to itch. It might be the contrast dye, or it might be just laying down for a long time with my face in a padded “donut.” The technologist scratches my nose for me. She asks me about my work, where I’ve traveled. We talk about kids and astronomy and endangered frogs and the importance of seeing the world. I love the technologist. I love the feel of her hand on my back.
Then they shoot the aluminum needle in. How can the radiologists do this? How can they bring together the mammograms, the MRIs, the ultrasounds in their heads? Back into the MRI to see if the needle is in the right place. Back out again. A small adjustment, back in again to double, double check. Back out again.
The attending decides they’ve got the spot. They start taking out cores. It sounds like a dentist drill and a slurpy vacuum. One sample, two. I think they take twelve. Best not to think that this is tissue coming out of my breast.
It’s over. I sit up. My favorite nurse compresses the area where the needles went in with her two hands. Bleeding is always a worry with core biopsies. They’re taking more than just a few cells. We sit there for ten minutes while she squeezes my right breast. She had breast cancer last year, she says, she understands what it’s like. She couldn’t sleep at all the night before her MRI-guided biopsy. Pink sisterhood is powerful.
As my favorite nurse and I chat, the radiology attending and his fellow are just outside the door, in the hall, looking at data and images, making sense of everything, visualizing my right breast, helping to find out if there’s cancer there. All hail to radiologists.