Breast Cancer Tumor Size Discrepancies and Treatment Options

Breast cancer size

Hello Doctor: I was diagnosed with breast cancer a month ago during a breast ultrasound at a clinic, where the doctor found "irregular breast calcifications." The ultrasound estimated the tumor size to be 1.3 cm, while the mammogram at the medical center estimated it to be 0.96 cm, and the PET scan estimated it to be 2.3 cm.
I am ER/PR positive and HER2 (1+) negative.
I started taking Letrozole for about a month before undergoing surgery, and I just completed a tumor excision surgery a week ago.
Yesterday, I received the comprehensive report from the breast cancer surgery, and the doctor informed me that the cancerous tumor was 4.4 cm, with no metastasis to the axilla! Initially, since the estimated tumor size was less than 3 cm, I was eligible for "intraoperative radiation therapy" as an out-of-pocket expense.
Although the actual tumor size was 4.4 cm, the doctor still performed "intraoperative radiation therapy." Afterward, I was informed that since the tumor was larger than 3 cm, I would need to have a radiation oncologist evaluate me for "postoperative radiation therapy" to prevent spread or metastasis.
I have a few questions for the doctor:
1.
Is it true that breast ultrasound, mammography, and even PET scans cannot accurately determine the size of the tumor? Is the actual tumor size of 4.4 cm difficult to predict due to the breast calcifications (branching type) that hinder precise measurement?
2.
My initial Ki-67 proliferation index was 40.
The doctor recommended that I take Letrozole for a month before surgery (I also received an injection to induce menopause) to facilitate monitoring the drug's effect on the tumor.
The postoperative report shows that the Ki-67 dropped to 3%.
Does this indicate that the drug has a very good effect on my treatment? I would like to know if a good response in the proliferation index does not necessarily mean that the drug can shrink the tumor.
Is it possible that the original tumor was larger than 4.4 cm? Why is it that we cannot accurately predict tumor size, and why are the estimates so varied?
3.
I have tubular carcinoma type B2; is the recurrence rate high for this type?
4.
Given my situation, would you recommend additional sessions of radiation therapy? 🙏 Wishing you peace and joy.

Yi, 50~59 year old female. Ask Date: 2024/01/19

Dr. Yuan Tianmin reply Breast and Thyroid

The first point regarding the size of the breast cancer tumor is that I am unclear whether a breast ultrasound was performed before surgery to confirm the size, given that you underwent hormonal therapy for one month prior to the operation.
If another ultrasound was not conducted, the surgical team may have assumed the tumor was only three centimeters in size at the time of surgery.
However, the actual tumor size post-surgery was determined to be four centimeters.
According to breast cancer treatment guidelines, it is still recommended that you undergo subsequent radiation therapy.
The hormonal therapy prior to surgery has been shown to decrease the proliferation index post-surgery, indicating that the preoperative hormonal treatment was effective.
However, it is important to note that changes in tumor size due to hormonal therapy require time to manifest.

Reply Date: 2024/01/19

More Info

Understanding the discrepancies in breast cancer tumor size and the subsequent treatment options is crucial for patients navigating their diagnosis and treatment plans. Your situation highlights several important aspects of breast cancer diagnosis and management, particularly regarding imaging techniques, tumor biology, and treatment efficacy.

1. Imaging Techniques and Tumor Size Discrepancies: The discrepancies in tumor size estimates from different imaging modalities (ultrasound, mammography, and PET scans) are not uncommon. Each imaging technique has its strengths and limitations. Ultrasound is often used for evaluating palpable masses and can provide real-time imaging, but it may not always accurately measure the size of tumors, especially if there are irregularities or calcifications present. Mammography, while useful for screening, can sometimes underestimate tumor size due to overlapping breast tissue or the presence of calcifications that obscure the tumor. PET scans can provide metabolic information but may also yield variable size estimates based on the tumor's activity. The actual size of 4.4 cm, as determined post-surgery, suggests that the tumor may have been more extensive than initially assessed. This is a reminder that imaging is an estimate and that definitive measurements are often only possible after surgical excision.

2. Effect of Hormonal Treatment on Tumor Size and Ki-67 Index: Your initial Ki-67 index of 40% indicates a high proliferation rate of the tumor cells, suggesting aggressive behavior. The significant drop to 3% after one month of treatment with Femara (letrozole) is indeed a positive sign, indicating that the hormonal therapy is effectively reducing the proliferation of the cancer cells. However, a reduction in the Ki-67 index does not necessarily correlate with a decrease in tumor size; it reflects the tumor's biological response to treatment. It is possible that the tumor was larger than 4.4 cm prior to treatment, but the imaging techniques failed to capture its full extent. Hormonal therapies can take time to impact tumor size, and the timing of imaging assessments can influence perceived effectiveness.

3. Type of Tumor and Recurrence Risk: You mentioned being diagnosed with tubular carcinoma (type B2). Tubular carcinoma is generally considered a subtype of invasive ductal carcinoma that tends to have a better prognosis compared to other types. The recurrence risk for tubular carcinoma is typically lower, especially when detected early and treated appropriately. However, individual factors such as tumor size, grade, and lymph node involvement can influence overall risk. Regular follow-ups and monitoring are essential to catch any potential recurrences early.

4. Postoperative Radiation Therapy Recommendations: Given that your tumor size exceeded 3 cm, postoperative radiation therapy is often recommended to reduce the risk of local recurrence, especially in cases where there is a higher risk of spread. The decision on the number of radiation sessions will depend on various factors, including the specifics of your tumor, margins, and overall treatment plan. Your oncologist will tailor the radiation therapy regimen based on these considerations.

In summary, the journey through breast cancer diagnosis and treatment can be complex, with many variables influencing outcomes. It is essential to maintain open communication with your healthcare team, who can provide personalized recommendations based on your unique situation. Regular follow-ups, imaging, and adherence to treatment plans are vital components in managing your health moving forward. Wishing you strength and health as you navigate this path.

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