Expert: Claes-Gustaf Nordquist, M.D. - 3/7/2009

Question
QUESTION: My mum was diagnosed with breast cancer last month. A fine needle
aspiration and biopsy of the axilla and supraclavicular lymph nodes were
performed and they were found to be malignant and consistent with
carcinoma. Subsequently, they performed CT scan, bone scan and MRI of the
breast and all of these turned out negative. Is it possible that she can have
Stage 4 breast cancer even when all imaging showed negative. Lab results
showed strong positive for AE1/2, 34E12 and HER2.

ANSWER: Yes it is unfortunately possible. It is not a probable situation - and therefore rare - but possible. In her case it probably means that her primary cancer in her breast is very small - less than a mm in size or so (an inch is 25.4 mm) - and therefore probably impossible to detect by MRI scans of her breasts. Unfortunately that also means that since it has already spread to her axillary and supraclavicular lymph nodes it is quite malignant. The possibility of finding early and therefore quite small more distant metastases now by CT scans and PET and other isotope bone scans is probably very limited and even doubtful. Only a mastectomy of her breast of interest and a serial sectioning of it in sections around one mm thick has any hope of finding her primary tumor - a HUGE undertaking by the pathologist and an enormous work load to do (a forensic pathology friend of mine once did the autopsy - in the late 1970'ies or early 1980'ies - of one of my private patients - a 19 years old girl - who had suddenly and unexpectedly died, the way she died indicated that there was a cardiovascular cause for it, but during the autopsy it was impossible to find the cause of her death, he did such a sectioning of her heart and was able to find a benign lymph vessel tumor about 1 mm in size strategically located within the electrical nerve system of her heart - that governed her heart activity - and therefore by disturbing it was the probable cause of her death, only 3 such cases had at that time been reported in the medical literature of the world). Your mother's tumor is at least a stage 3 (III) and probably a stage 4 (IV) by now. I'm sorry I have nothing better to tell you!


---------- FOLLOW-UP ----------

QUESTION: Thanks for your opinion doc. I have 2 other questions-
1. Do you think it would be necessary to reperform the lab test? I am trying to rule out a mix up of the lab work and wonder if fine needle aspiration would be a good option since it is not too invasive and costly?
2. My mum was invited to embark on a clinical trial of Pertuzumab‏. What is your opinion of the trial given the situation and she has not started treatment yet.

Answer
1. Probably not but if it can lessen your worries by all means why not?! Fine/thin needle aspiration biopsies would be OK (one of my former bosses,  the late professor Sixten Franzén, M.D., Ph.D., was one of the developers of that technique) provided there is still anything to take the biopsy from. If her axillary & supraclavicular lymph nodes have been surgically removed that may be difficult. To do it from any primary tumor in her breast is impossible since we can not detect it and therefore do not know where to aim the needle.
2. Yes that is probably a good idea based on your presentation of her tumor.