A 47-year-old female consulted me in March 2018 with concerns of lymph nodes and breast ultrasound report of BIRADS 4B – moderate suspicion for malignancy.
When I saw the patient and asked her what was her main concern, she said axillary lymph nodes. When I did a physical examination of her axillae, there were no palpable lymph nodes on the axilla. Then, I asked her, what was her “real” concern.
She then said she previously went to two private medical centers for her breast check. In the first center, she had mammography and ultrasound. The report showed BIRADS- 4B. She went for a second opinion in the second center. She was advised to have a repeat ultrasound of the breast which showed BIRADS 3 (probably benign findings). However, a surgeon in the second center advised her to have her axillary lymph nodes removed (meaning the recommendation is an operation).
She was so alarmed and anxious that she could not sleep for 2 weeks before she consulted me (for a 3rd opinion).
Having more information gotten from the patient, I repeated my physical examination – examining the breasts and the axillae, neck and the groin for enlarged lymph nodes.
Results of my physical examination showed no dominant breast mass on her two breasts, just fibrocystic changes, and no enlarged lymph nodes in the axillae, neck and groin.
When I reviewed her imaging results, I saw a mammography with no signals for cancer. I saw two ultrasound reports with differing opinions, one BIRADS 4B and the other BIRADS 3. I scrutinized at the report showing BIRADS 4B. The suspicion of malignancy just came from the presence of so called “diminution of central fat” in the axillary lymph nodes (right and left). There was nothing on the breasts that were suspicious for malignancy. Scrutinizing the report showing BIRADS 3, there multiple cystic nodules on both breasts and non-specific lymph node enlargement. Correlating these imaging results and my physical examination, I told the patient my primary clinical diagnosis is fibrocystic changes. There was no need for operation. Just observe. Just monitor.
The surgeon in the second private medical center advised her to her axillary lymph nodes removed because of the report of the radiologist in the first medical center. Reason given – just to be sure there is really nothing wrong in the axillary lymph nodes.
My approach is different. My primary clinical diagnosis on the axillary lymph nodes seen on ultrasound was that they are either normal or nonspecific inflammatory changes, more likely the former, as this was the finding in the ultrasound in the second medical center and I was not able to palpate any enlarged lymph nodes. I don’t go by the reason “just to be sure, operate.” I go by the probability of the clinical diagnosis. With a high probability, more than 98% (based on experience), that the axillary lymph nodes are normal or at most nonspecific enlargement, I go for observation, monitoring, and wait and watch approach.
I told this to the patient and there a great sigh of relief. I saw tears of joy flowing from her eyes.
I was also extremely happy that day because I was able to avoid an unnecessary operation for the patient (my personal belief) and for another patient. I told myself that if one day I will be incapacitated to do surgery because of age and other reason, at least I can continue to properly advise patients particularly on the diagnosis and whether an operation is needed or not.