Navigating Rare Breast Cancer Treatment: Seeking Guidance for Unusual Cases

Q: Navigating Rare Breast Cancer Treatment: Seeking Guidance for Unusual Cases

Dear Jason： The principle of positron emission tomography (PET) is to utilize glucose labeled with radioactive elements to detect areas in the body with particularly high metabolic rates. <br>It is generally assumed that tumor cells have a higher metabolic rate than normal tissue

Treatment for breast cancer patients with special conditions - please help!

Hello, doctor! We truly value medical resources, but we are feeling quite lost, which is why we are seeking your advice.
My mother was diagnosed with breast cancer at the He Shin Cancer Hospital in May this year, with a 0.8 cm tumor confirmed as malignant after a biopsy.
The breast surgeon determined it to be stage I.
After breast ultrasound, mammography, and neck and abdominal ultrasounds confirmed no metastasis, she underwent a surgical local excision at the end of June.
During the surgery, a biopsy confirmed lymph node metastasis, and all axillary lymph nodes were removed, totaling 44 lymph nodes, of which 33 were found to be metastatic.
Post-surgery, due to the slow processing of reports from He Shin, we went to Shin Kong Hospital for a PET scan, which revealed that the axilla was not completely cleared and there were two shadows on the clavicle.
The He Shin physician indicated that this type of breast cancer is rare, as tumors smaller than 1 cm typically do not metastasize this quickly.
Fortunately, the bone scan from He Shin showed no metastasis.
The subsequent treatment has become chaotic; the original breast surgeon went abroad, and last Tuesday the oncology department stated that chemotherapy should begin, so an implanted port was placed.
However, after reviewing the PET scan results, they halted the process, suggesting a surgical consultation to see if further excision could be performed.
This past Monday, my mother was called to the surgical outpatient clinic, but the oncologist and the substitute surgeon could not reach a conclusion.
The next day, they called to say that on Thursday, they would discuss hospitalization for chemotherapy, which is currently tentatively planned as 3 cycles of Adriamycin, followed by 3 cycles of Taxol, and then 3 cycles of oral chemotherapy, with treatments every two weeks.
However, the surgical team still has no answers.
We are considering transferring to another hospital, but due to the primary physician being out of the country, He Shin is unwilling to provide the surgical records.
My questions are: 1.
Is there anyone with related experience where a small breast tumor resulted in significant metastasis to the axillary lymph nodes? How quickly does such cancer typically progress? 2.
Is there anyone who can share similar experiences regarding treatment methods and physicians, and their effectiveness? 3.
In the absence of a definitive conclusion from the physician, is it feasible to proceed with chemotherapy as a trial approach? 4.
Given that the PET scan shows residual lymph node metastasis in the clavicle and axilla, is it appropriate to begin the aforementioned chemotherapy?

Jason, 30~39 year old female. Ask Date: 2007/08/02

Dr. Fan Sheng reply Oncology

Dear Jason: The principle of positron emission tomography (PET) is to utilize glucose labeled with radioactive elements to detect areas in the body with particularly high metabolic rates.
It is generally assumed that tumor cells have a higher metabolic rate than normal tissues, so PET can be used to detect tumors.
However, inflamed tissues also exhibit a higher metabolic rate than normal, and the tissue around a recently operated wound is likely to show an inflammatory response.
Therefore, I believe that the current shadow could potentially be a tumor or an inflammatory response; of course, it is best to have a nuclear medicine specialist interpret the results for the most reliable assessment.
The breast surgery department at He Shin is well-known, and the axillary lymph nodes should have been thoroughly cleared.
I suspect that the chances of needing another surgery are low, and furthermore, metastases near or above the clavicle are not easy to surgically remove.
However, localized radiation therapy could be considered, so please consult with the attending physician about that.
The presence of such extensive axillary metastasis indicates a very aggressive form of breast cancer with a high recurrence rate.
Theoretically, there is a significant possibility of systemic metastasis that PET may not detect.
Therefore, it is advisable to proceed with chemotherapy promptly.
Additionally, if the tumor shows strong HER2 marker expression, please consult with the attending physician about the possibility of using the monoclonal antibody Herceptin out-of-pocket to enhance treatment and prevent recurrence.
Wishing you all the best!

Reply Date: 2007/08/02

More Info

Navigating the complexities of breast cancer treatment, especially in rare cases, can be overwhelming. Your mother's situation, where a small tumor (0.8 cm) has led to significant lymph node involvement (33 out of 44 lymph nodes affected), is indeed unusual and raises several important considerations regarding treatment and prognosis.

1. Aggressiveness of the Cancer: Typically, smaller tumors (especially those under 1 cm) are associated with a lower likelihood of metastasis. However, the presence of extensive lymph node involvement suggests that the cancer may have aggressive characteristics. The rate of progression can vary significantly among individuals, and while some cancers may remain indolent, others can behave more aggressively despite their initial size. The fact that your mother’s cancer has already shown significant lymphatic spread indicates that close monitoring and prompt treatment are crucial.

2. Treatment Experiences: While there may not be a wealth of publicly available data on cases exactly like your mother’s, it is not uncommon for patients with small tumors to experience unexpected lymphatic spread. Treatment protocols often involve systemic therapies such as chemotherapy, especially when there is evidence of lymph node involvement. In such cases, oncologists may recommend chemotherapy followed by radiation therapy, depending on the overall response and any residual disease. It would be beneficial to connect with support groups or forums where patients share their experiences with similar diagnoses, as personal anecdotes can provide insights into treatment paths and outcomes.

3. Chemotherapy Decisions: Initiating chemotherapy without a definitive surgical plan can be a contentious issue. In general, oncologists prefer to have a clear understanding of the disease's extent before starting systemic therapies. However, in cases where the cancer is aggressive, they may opt to begin chemotherapy to control the disease while planning for surgery. The proposed regimen of 3 cycles of AC (Adriamycin and Cyclophosphamide) followed by 3 cycles of Taxol (Paclitaxel) is a standard approach for managing breast cancer with lymph node involvement. It is essential to weigh the potential benefits of starting chemotherapy against the risks of delaying surgical intervention.

4. Addressing Residual Disease: The findings from the PET scan indicating residual disease in the supraclavicular lymph nodes are concerning. Starting chemotherapy while there is known residual disease can be a double-edged sword. On one hand, it may help to control the spread; on the other hand, it could complicate surgical options later. Ideally, a multidisciplinary team should discuss the best course of action, considering both the oncological and surgical perspectives.

5. Seeking Second Opinions: Given the complexity of your mother's case and the uncertainty surrounding her treatment plan, seeking a second opinion from another institution or a specialized cancer center may provide additional clarity. It’s essential to have a treatment plan that all involved specialists agree upon, especially in cases where the primary oncologist is unavailable.

In conclusion, your mother's case is indeed challenging, and the rapid progression of her disease necessitates a well-coordinated approach involving both oncologists and surgeons. Open communication with her healthcare team, seeking second opinions, and exploring patient support networks can provide valuable resources and guidance as you navigate this difficult journey. It’s crucial to remain proactive and advocate for a treatment plan that addresses both the immediate and long-term needs of your mother’s health.

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