Expert: Claes-Gustaf Nordquist, M.D. - 3/12/2009

Question
QUESTION: Hey doc, we have approached 2 docs here on my mum's swollen
lymph nodes
at her axilla and supraclavicular and it appears that the docs have different
treatment plans. Given my mum only tested positive on lab test and all other
tests such as MRI of breast, CT scan and bone scan are negative and she has
no symptoms to show at this stage, the first group of doc plans to put her on
chemo and clinical trial (Pertuzumab + Trastuzumab + Docetaxel) while
the second group of doc plans to perform axillary clearance followed by
chemotherapy and then whole breast and supraclavicular node irradiation. To
me, it seems that the first group is using a rather general approach while the
second group steers towards more specificity to me. Given your experience
and knowledge, which would be a better approach to treat my mum's case?
Or how would you treat my mum given the information that I have presented.
Answer     Well, it seems I'm for a third method. Mastectomy and perhaps
axillary surgery followed by radiation to her supraclavicular nodes (and
perhaps her axillary nodes if no surgery there - or maybe even after surgery
there but that is uncertain, high risk of side effects). After that chemotherapy
more or less according to the advice of the first group. If her cancer is
hormone receptor positive hormone treatment too. I think that due to the
aggressive behavior of this cancer it must be treated in an aggressive way
too!
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Thanks doc. In view of the uniqueness of my mum's case, is chemotherapy an
absolutely necessary measure for my mum or it should be used as as "wait
and see" depending on how the surgery and radiation turn out given that only
her axilla and supraclavicular areas are affected by the carcinoma cells? In
your experience, are there any known adverse effects of just surgery or
radiation of areas of the axilla and supraclavicular area?

Answer
You have interpreted my reply in the wrong way. Since her cancer has spread in this rather unique way very early from an obviously very small primary tumor it MUST be a rather aggressive cancer! In that case you can not afford to wait! Her cancer is NOT waiting, it is probably growing. That both these lymph node areas are affected so early is a BAD sign! So she does need chemotherapy too that is essential!