SHOULD TISSUE HAVE BEEN OBTAINED FROM A PULMONARY LESION?

The characteristic radiologic appearance of these nodules for pulmonary metastases led me away from putting the patient through an invasive procedure. I decided to do an in vivo test of diagnosis by observing the increase or decrease of the lung nodules relative to the breast mass, assuming that if the breast mass decreased in response to therapy, the pulmonary lesions would follow suit. Over the course of this patient’s treatment, this did correlate very well. I probably would have used the same philosophy even if the tumor were ER-negative — initiating first-line chemotherapy and observing for response.

—Kevin Fox , MD

The problem in this patient is the level of confidence that this is metastatic disease. Obviously, this makes a world of difference in both her treatment and her plans for the rest of her life. Although the clinical picture is more than highly suggestive of metastatic disease, I feel that she deserves the rule-out manner of thinking.

If the patient were willing, my initial recommendation would be for obtaining lung tissue.

—Patricia Madej, MD

I would absolutely get tissue to confirm the diagnosis of metastases. Usually my first choice is a CT-guided lung biopsy. If the lesions are too small, we usually do a video-assisted thoracoscopy to get the diagnosis. I would not give her a diagnosis of Stage IV disease — no matter how typical it looked — unless I exhausted every possibility of obtaining tissue.

—Linda Vahdat, MD

LOCAL THERAPY OF 4cm BREAST MASS
Comments from a panel discussion at the 3rd Annual Lynn Sage Breast Cancer Symposium, October 2001

Time is not of the essence for making a local therapy decision in metastatic disease. It is okay to see how a patient is doing and see her back in eight weeks when she’s going to the medical oncologist anyway to give you an idea of what’s going on as far as the necessity of local control. There are very few patients with metastatic disease who need to come to surgery. I would do it only if I thought we were going to get into local failure problems. This never occurs quickly, so there is plenty of time to rediscuss and have the medical oncologist perhaps rethink the systemic treatment. If the disease is not causing any skin breakdown, a large amount of pain or anything in particular beyond its presence, observation might be appropriate.

—Jeanne Petrek, MD

I’m not aware of any data clearly showing the benefit of doing local therapy. I would side with just watching a patient like this and continuing the systemic therapy. This would change if it became a local problem, if the disease were breaking down the skin, etc. But other than that, I’m not aware of any data to support removing the primary lesion.

—William Gradishar, MD

It’s an interesting biological question that you could argue one of two ways. The kidney cancer people have data suggesting that if you take out a primary renal cell carcinoma in the presence of metastasis, you live longer ²⁶ . On the flip side, the “Folkmanesque” approach to tumor dormancy ^27-32 suggests that the primary tumor might be producing something that suppresses the metastases — if you take out the primary tumor, the metastatic tumor might explode. You can call it either way from a biologic standpoint, but in breast cancer, we just simply don’t have any decent data.

— George Sledge, MD

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