Palpable Supratrochlear Lymph Nodes

[LMALM53]

I was dx'd at age 47 in 2000 with Stage 2 IDC of the right breast.  Had Lumpectomy, AC/Taxol chemo, radiation and tamoxifen.  Did well until late 2005 when I was dx'd with a new primary breast cancer in the left breast.  This time it was a Stage 3c, 5.1cm ILC with 23/23 nodes positive.  Had bilateral mastectomy, Xeloda/Taxotere chemo, 3 field radiation and am currently taking daily Aromasin plus IV Zometa every 3 months.  Developed Stage 2 lymphedema of the left arm less than 3 months after surgery.

Dec 5th, 2007 was my 2 year anniversary of the bilateral mastectomy and so far my 3 month checkups and 6 month CT body scans have been normal.  I am due for my next CT body scan in Jan 2008.  Just had a 3 month checkup yesterday and brought to my surgeons attention some palpable lymphnodes at the right antecubital area.  Largest one about 4-6mm in size, firm, nodular, not painful.  My surgeon felt a PET scan might be preferable to CT.  My medical onc then examined same area and felt unlikely to be cancer since nodes are only palpable on extension of the elbow and no palpable nodes felt behind the elbow.  Medical onc feels a PET scan has a high false positive rate will not give any more useful information than a CT scan will. I am having my scheduled CT scan in 4 weeks.

Is there any criteria for determining when a PET vs CT is better for specific diagnoses?  I am also concerned that my right arm is currently not affected by lymphedema but is certainly at risk for LE due to my surgical history. If a CT scan shows there is abnormal activity at the supratrochlear nodes, would standard treatment include a nodal biopsy?  I understand that correct diagnosis and treatment of a potential breast cancer mets or lymphoma is important, but I also am intent on preserving what few lymphatic drainage sites I still have and hope to prevent additional limbs affected by LE.  

What would be the recommended medical approach with someone already having LE in one extremity and at risk in the limb that presents with palpable supratrochlear nodes?

[Dennis MD]

Hi.
I understand what your are going through.

A PET scan involves injection of radiolabeled tracer prior to the actual imaging.  When cancer is present, the tracer will localize to the site/s of cancer.  This can provide relevant information on tumor detection, staging, and treatment response.  Applications of PET scan include non-small cell lung cancer, breast cancer, colorectal cancer, head and neck cancer, esophageal cancer, thyroid cancer, and lymphoma.  Newer technology includes the combination of PET and CT scan (PET/CT) which increases the resolution of images gathered.

A CT scan, on the other hand, uses ionizing radiation beams that is passed at different angles to the patient's body (particularly the area of interest) and analyzed by a computer.  CT scan can show the extent of tumor, distinguishes between normal and abnormal areas.

If on diagnostic imaging there is suspicion of cancer (in your case, the supratrochlear nodes), a biopsy is needed in order to confirm the diagnosis.  In the setting of previous surgery (MRM with axillary lymph node dissection), the risk of developing edema secondary to the supratrochlear node biopsy is very, very minimal.  

Lymphedema is one of the complications of breast cancer treatment.  The extent of the surgical dissection correlates with the development of edema. In patients who already developed lymphedema, there are various techniques in order to decrease its size.  Manual lymphatic drainage can be applied by doing massage on the area involved. Wearing compression garments can also be done.

It would be best to wait for your diagnostic imaging result first.  If there is a suspicion of cancer in the involved node, a biopsy can be done in order to confirm the diagnosis.

Good luck.