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are here: Home: BCU 6|2001: Program Supplement: Dr. Petrek
DR. LOVE:
One interesting aspect of this case that I did not discuss with Dr
Fox was management of the primary lesion in the breast. Although it
seems evident that like many treating physicians in this situation,
he was using systemic therapy to not only manage the metastatic disease,
but also to control the primary lesion. And in fact, he noted that
the palpable breast mass decreased in size with endocrine therapy.
Interestingly, at the recent Lynn Sage meeting, Dr Monica Morrow presented
a similar case to an interdisciplinary panel. Like Dr Fox's patient,
this woman had a 4 cm primary lesion and metastases, in this case
to the bones. In the discussion that ensued, one point related to
local management of the primary lesion, and surgeon Dr Jeanne Petrek,
Dr Morrow and radiation oncologist, Dr Larry Solin, addressed this
question. After which, medical oncologists Dr Bill Gradishar and Dr
George Sledge discussed the potential systemic impact of removing
the primary lesion. Dr Petrek began by noting the secondary role of
surgery in this situation.
DR. PETREK: I think that it is a disease that time is not
of the essence, so that to see how a person is doing and to see
them back in eight weeks when they're seeing their medical oncologist
anyway gives you an idea of what's going on as far as local control
is necessary, so that it's been very few patients with metastatic
disease who need to come to surgery.
DR. MORROW: So, if they have progression of their local
disease but not progression of their metastatic disease, that's
the time that you would do it, when you think you're going to get
into local failure problems?
DR. PETREK: Right. And it never occurs quickly, so that
there's still plenty of time to re-discuss, to have the medical
oncologist perhaps rethink their systemic treatment, and it's the
same, I suppose, as a visceral crisis. If this particular disease
is not causing any skin breakdown, any large amount of pain, anything
in particular beyond its presence, observation might be appropriate.
I think the least appropriate would be radiation alone, because
it would be quite the treatment and it wouldn't work.
DR. MORROW: Larry, do you ever radiate the intact primary
tumor?
DR. SOLIN: I think the size of this mass would really preclude
that. At 4 centimeters the time and the dose would be prohibitive.
So, lumpectomy as another alternative one could do. It would be
an outpatient procedure. It would be low morbidity, and it would
remove the bulk tumor mass, leaving the intact breast. But I think
Jean's approach is probably the one we would choose, which is just
observation.
DR. MORROW: Certainly that's been our traditional approach
to metastatic disease. Let me ask either of you if you think that,
in patients who have stable, non-progressive disease, if there is
any role for local therapy as a means of removing the largest area
of residual tumor. Do you think that that could have any value in
extending the duration of a patient's remission, or purely for local
control?
DR. GRADISHAR: Yeah. I'm not aware of any data where there
would clearly be shown to be of benefit. I would side with just
watching the patient, continuing the therapy. I think the only issues
would be if, it became a local, sort of toilet mastectomy issue
of if the disease were breaking down the skin or something like
that. But other than that, I'm not aware of any data.
DR. SLEDGE: We really don't know. It's kind of an interesting
biological question that you, I imagine, could argue one of two
ways. You know, 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. On the flip side, we've got the "Folkmanesque"
approach to tumor dormancy, that suggests that the primary tumor
might be producing something that, in some way, is suppressing the
metastasis and that, if you take out the primary tumor, the metastatic
tumor might explode. So you can call it either way from a biologic
standpoint, if you want. But in breast cancer, we just simply don't
have any decent data.
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