Expert: Claes-Gustaf Nordquist, M.D. - 3/25/2011

Question
QUESTION: my mother was having lump in outer upper quadrant right breast with no axilla lymph node present.
on mammogram irregular lump 2*2.2*1.5 cm with no microcalification or speculation was found.
Axilla USG shows no Lymph node enlargement.
FNAC was reported fibroadnomatiod hyperplasia.
then we did work up and did wide local excision of lump , biopsy report came out as infilterating ductal carcinoma , nottiangam grade II wit R.B sccore 2+2+2=6 , with DCIS comedo type also seen, all surgical margins are free from tumor. Now i want to know what will my further course of action, is mastectomy with axillary dessection required ,or radiotherapy/ chemotherapy , which will be best, kindly advise

ANSWER: How big was her cancer according to her pathology report? I do need to know that to answer. The only measurements I have are from her mammography report but those numbers are uncertain since there is probably fibroadenomatous tissue there as well as verified by her FNAC and a cancer in situ (or cancer stage 0) usually is far smaller than those measurments indicate. It is best if you can let me read the full pathology report. You can copy it here.


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

QUESTION: histopath report:
on serial sectioning a homogenous grayish white tumor is identified measuring 28*15*12 mm. the nearest surgical margin is superolateral margin which is 24mm away, 30mm form lateral margin and 12mm form deep surface. it is far from all other margin.no cyst or heamoraage seen. one area shows fiborsis.
microscopy:
section show infiltrating duct carcinoma , grade II. modified R.B score 2+2+2=6. tubule fromation is extensive,solid and cribriform type DCIS is seen. Comedo type necrosis is seen. Mitotis figure are 1-2/HPF. lymphovascular emboli are seen, perineural invasion is present. desmoplasia and calcification are present. tumoe associted lymphocytic response is seen. all margin free from tumor.

ANSWER: This can NOT be considered a cancer in situ (cancer stage 0)! This must be considered to be an invasive cancer - or better it IS an invasive cancer. And not small. So I must advise you that a mastectomy is best with an axillary dissection. What has to be done next depends on the result of the pathology examination of that surgical specimen. So please keep me posted, here or on my other site (see below). Thanks!





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

QUESTION: sir,
thanx for ur support, i got my mother MRM done on 14/3/11 and now hisyopathology report show 1/26 lmph node level I metastatic deposits with all margins clear and no DCIS and NO lymphovascular invasion of tumor. ER +ve and PR +ve and her2neu 2+ , so what should be next treatment , what chemotherapy regime should we take and what homone therapy. please guide, do we need radiation therapy or not

Answer
Since it seems her breast cancer has spread to at least one lymph node it must be considered to be a stage 3 breast cancer. It is also hormone receptor positive and Her2 positive. So I do suggest radiation therapy AND standard chemotherapy including Herceptin! And (anti-)hormonal therapy (here an aromatase inhibitor would probably be best with a 5 year period of treatment). Good luck!



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SORRY, you are gravely mistaken! And it is not me but you who has to revise your attitude here or your wife will not receive the treatment she needs and deserves! 1. It IS enough with one lymph node metastase to make it a stage 3 tumor - why are we otherwise looking at sentinel lymph nodes, one is enough? 2. Her tumor is a so called triple positive breast cancer (positive hormone receptor tests both for estrogen & progesterone AND a positive HER2 test). Such cancers are usually more aggressive and that is why I also recommend both radiation therapy AND chemotherapy! Since it is this kind of tumor AND as I wrote above also a stage 3 tumor chemotherapy is also needed. But since it is a HER2 positive cancer Herceptine SHOULD also be given to get a good enough effect! So chemotherapy is a MUST and so is this particular drug! 3. Triple positive cancers are more aggressive but that is not ONLY a liability it is also an asset since you have the possibility of using Herceptin (of no use in Her2 negative cancers) and since it is hormone receptor positive also (anti-)hormonal treatment can be given - also of no use in hormonal receptor negative cancers. So discuss her treatment with her doctors and you will discover that I'm right and you are wrong! Besides a cancer of 28x15x12 mm, with invasive growth and which has spread to a lymph node can NOT be considered a small early cancer. That is what I told you from the beginning and which resulted in her mastectomy and the discovery of her invaded lymph node. So you have received the same message from me the whole time and what I told you was confirmed by the finding of her invaded lymph node and these other test results. This is NOT a rather harmless small early breast cancer - if it had been that no mastectomy would have been needed, a lumpectomy as was done in the beginning would have been enough followed by radiation therapy of her breast and her breast could have been spared. So talk to doctors and you will find out! Otherwise you are doing your wife a disservice!

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