Mets to Nodes

[medical1]

I underwent a L mastectomy 19 months ago for invasive ductal BC, with a tumor size of 0.7, all nodes negative, ER / PR neg with a very positive Her2. I was advised by 2 oncologists that no further treatment was needed, just routine visits.  I have been undergoing reconstruction for 2 1/2 months with a tissue expander in place. I noticed a lump on my neck, subclavicular area. It was removed and the test results showed malignancy 3/3 lymph nodes, with identical features of the BC, Her2 etc.  They are calling this mets to the neck. I underwent a bonescan, bloodwork, and a lung, liver and pelvic CT, results are not back yet. All this is so shocking to me as I feel so good....the oncologist at a large cancer hospital here is recommending radiation to the neck and Herceptin q3weeks IV for 5-7 years.  Should I be receiving chemo also or will the Herceptin control this. Thank You

[Damabelle]

I am in a similar situation to what you were 18 months ago.  I am 37 and have recently been diagnosed with breast cancer, and had a lumpectomy and axillary dissection about 4 weeks ago.  Pathology found a 2.5cm primary, nottingham grade 3+3+3 tumour with a ~.5cm border of DCIS, one lymph node out of seven sampled involved (lymph node 5cm x 3cm x3cm with extranodular involvement).  Fortunately scans for secondaries haven't revealed any other mets (They did a bone scan, CTscan and ultrasound of abdomen and pelvis, colonoscopy, Brian MRI).

Like you, my tumour was ER/PR negative and highly (3+) Cerb-b2 positive.  Because my Tumour is more advanced than yours was when it was detected, I have been advised to get chemotherapy and radiation therapy straight away starting next Tuesday(4x adriamycin and cyclophosphamide 21 day cycles, followed by radiation therapy, followed by a series of taxane cycles(probably taxol, pacitaxel or taxotere). From what my oncologist has said over here it sounds like Taxols are usually used for cancers with secondaries, and it can be difficult to get approval to use it here if adriamyacin is not used first).  From what I have read it is different in the states.

I have been asking about herceptin, but adjuvant therapy using herceptin is not available in Australia at the moment ( costs over $45,000 if not subsidised), and there doesn't seem to be any clinical trials available here except for advanced disease (IE stage IV with Mets).  Herceptin specifically targets cells that overexpress a cancer protein (your tumour does this if it is Cerb-b2/NEU positive), and research sounds very positive for our kind of tumour.

Anthrocyclins, particularly Adriamycin, are considered one of the best chemotherapy agents for ER/PR negative tumours, but it can be a little harsh on your heart and the effect is dose related, so there is a maximum lifetime dose of adriamycin that can be given.

There is evidence that adriamycin and herceptin are a bad combination, and about 21% get some degree of Congestive heart failure due to cardiotoxic effects if the two are used in combination.  I have read somewhere that this risk is reduced if at least 4 months separates the admistration of herceptin and adriamyacin.  One chemotherapy drug that does seem to be used quite a lot with herceptin is taxotere (a type of taxan?), maybe you could ask your doctor more about this one?

It would also be a good idea to ask your doctor about any clinical trials in your area.

http://www.vmmc.org/dbCancerClinical/sec2375.htm

Good Luck....

Regards

Anne

[CCF-RN,MSN-rf]

Dear medical1:  The answer to your question depends on the results of your scans.
  
If your scans are positive for metastic disease,chemotherapy may be recommended, combining chemotherapy drugs with herceptin.
If your scans are negative, a PET scan may provide additional reassurance of low/negative tumor burden.

If your workup is negative, then you can pursue radiation and be maintained on Herceptin.  There's no clear benefit in this situation to starting chemotherapy.  However, given the high likelihood of recurrence, it would be reasonable to monitor closely - every 3-6months with CT and bone scans.  If and when there is a recurrence, You could review your treatment options, with likely treatment involving chemotherapy + herceptin.

[medical1]

Bone scans and CT's were all negative, with exception of a few swollen lymph nodes in armpit of mastectomy side...unsure if this is also mets or due to inflammation from tissue expander.