Lymph Node Biopsy in Invasive Ductal Carcinoma Treatment

Questions about lymph node biopsy?

Hello Dr.
Chen, I was diagnosed with invasive ductal carcinoma in mid-December this year.
The tumor is located in the lower inner quadrant of the right breast, approximately at the 3:30 position, 4 cm from the nipple.
The ultrasound estimated the size to be about 1.95 x 1.53 x 2 cm.
The core needle biopsy report indicates the following: triple positive - ER: positive (80%, variable intensity: intermediate to strong), PR: positive (65-70%, variable intensity: intermediate to strong), HER2: positive (Score 3+/3+), Ki-67 index: around 20%, Grade III.
It is currently estimated to be stage II.
The oncologist has tentatively prescribed a treatment regimen of Epirubicin, Carboplatin, and Herceptin for 6 to 8 months of neoadjuvant therapy.
I would like to ask the following questions:
1.
Currently, the examinations include ultrasound, core needle biopsy, and mammography.
Bone scan and CT will be performed later.
What is the accuracy of these examinations in detecting lymph node involvement? Is there a need to request a lymph node biopsy from the doctor?
2.
Since the tumor is located near the inner side, what methods can be used to assess whether there is metastasis to the internal mammary lymph nodes? I do not have any other commercial insurance, and given my stage II status, the neoadjuvant treatment with Herceptin and Epirubicin is not covered by health insurance and must be paid out of pocket.
This is a significant expense for me, requiring borrowing money from friends and family.
Therefore, I hope to have a more detailed examination of the lymph nodes to facilitate this.
I am unsure of what other methods can confirm this (besides surgery, as I have already decided to proceed with neoadjuvant therapy).
I appreciate any advice you can provide, thank you.

Gu Gu, 20~29 year old female. Ask Date: 2022/12/17

Dr. Chen Sirong reply Oncology

Hello, I'm 27 years old female.

1.
Currently, I have undergone ultrasound-guided core needle biopsy and mammography.
I will also have a bone scan and CT scan later.
I would like to ask about the accuracy of these tests in determining whether there is an infection in the lymph nodes.
Should I request my doctor to perform a lymph node biopsy?
A: It is not recommended to use invasive biopsy procedures for diagnosis; positron emission tomography (PET) imaging can be used for diagnosis.
2.
Since the tumor is located near the inner side, I would like to know what methods can be used to detect whether there is metastasis to the internal mammary lymph nodes?
A: It is not recommended to use invasive biopsy procedures for diagnosis; positron emission tomography (PET) imaging can be used for diagnosis.
3.
As I currently do not have any commercial insurance and am in stage II, the preoperative treatments with Hecare and Ozu are not covered by health insurance and must be paid out of pocket, which is a significant expense that requires borrowing money from family and friends.

A: You can discuss other options with your physician, such as:
3.1 Performing surgery first and then deciding on chemotherapy based on the postoperative pathology report.

3.2 Only opting for treatments covered by health insurance.

Wishing you a successful treatment.
Taoyuan Hospital, Dr.
Chen Sih-Rong.

Reply Date: 2022/12/17

More Info

Understanding lymph node biopsy in the context of invasive ductal carcinoma (IDC) treatment is crucial for determining the appropriate management strategy and prognosis. In your case, you have been diagnosed with invasive ductal carcinoma, and the treatment plan includes neoadjuvant therapy with a combination of chemotherapy agents. Here’s a comprehensive overview of the relevant aspects regarding lymph node involvement and biopsy.

1. Importance of Lymph Node Evaluation
Lymph nodes are critical in the staging and management of breast cancer. The presence of cancer cells in the lymph nodes often indicates a higher stage of disease and can influence treatment decisions. Invasive ductal carcinoma can spread to nearby lymph nodes, particularly those in the axillary region. The evaluation of lymph nodes is typically done through imaging studies, such as ultrasound and mammography, and may be confirmed with a biopsy.

2. Accuracy of Current Diagnostic Tests
The tests you have undergone, including ultrasound and core needle biopsy, provide valuable information about the tumor and its characteristics. However, these tests may not always accurately reflect lymph node involvement. For instance, imaging studies can suggest lymph node involvement, but a definitive diagnosis often requires a biopsy. If there is a suspicion of lymph node metastasis based on imaging, a sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) may be recommended.

3. Need for Lymph Node Biopsy
Given your situation, if there is a significant concern regarding lymph node involvement, it may be prudent to discuss the possibility of a lymph node biopsy with your oncologist. This procedure can provide definitive information about whether cancer has spread to the lymph nodes, which is essential for staging and treatment planning. If the biopsy shows no involvement, it may allow for a more conservative treatment approach.

4. Methods to Assess Internal Mammary Lymph Nodes
The internal mammary lymph nodes can be more challenging to assess due to their location. While imaging studies can provide some information, they may not be definitive. Techniques such as ultrasound-guided fine needle aspiration or sentinel lymph node biopsy can help evaluate these nodes. However, these procedures may not always be feasible or covered by insurance, especially if you are facing financial constraints.

5. Financial Considerations and Treatment Decisions
It’s understandable that the financial burden of cancer treatment can be overwhelming. Discussing your concerns with your healthcare team is essential. They may be able to provide options for financial assistance or alternative testing strategies that are less costly. Additionally, some hospitals have programs to help patients manage the costs of treatment.

6. Next Steps in Your Treatment Plan
Since you are scheduled for neoadjuvant therapy, the focus will be on reducing the tumor size before surgery. This approach can also provide insight into how the cancer responds to treatment, which can be a positive indicator of the effectiveness of the therapy. After completing the neoadjuvant treatment, further evaluation of the lymph nodes may be necessary, including possible surgical intervention to assess their status.

Conclusion
In summary, understanding the role of lymph node evaluation in invasive ductal carcinoma is vital for effective treatment planning. While current imaging studies provide some insights, a definitive diagnosis often requires biopsy. Discussing your concerns about lymph node involvement and financial implications with your oncologist is crucial. They can guide you through the necessary steps and help you make informed decisions regarding your treatment. Remember, you are not alone in this journey, and there are resources available to support you through this challenging time.

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