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What Do The Following PET Scan And Mammography Report Indicate?
Question: Hi,
Continuing from our last thread
http://www.healthcaremagic.com/AskDoctorInboxServlet?page=viewQuery&queryId=182718
A))I was looking at my Mom's previous reports (all of them attached)
1. Mammography - This was done on 15th January and it showed no abnormality to Axilla (Bilateral axilla are normal)
2. PET - This was done on 2nd Feb after the FNAC which led to an inflammation and infection and swelling of the entire left breast. The swelling was quite prominent. The PET scan found a few metabolically active Level 1 lymph nodes (Few discrete FDG avid lymph nodes noted at axilla level 1)
3. Ultra sound - This was done on 3rd Feb, a day after PET. The swelling was still there and unlike the mammogram done earlier, this ultra sound found swollen lymph nodes (most likely due to the inflammation) (report says - few enlarged lymph nodes are seen in the left axilla)
4. Ultra sound - We did this one recently to check the size of the tumor. The tumor has reduced a lot in volume (I am guessing ~ 90%). Also, it did not find any enlarged lymph nodes.
Now, since the PET was done at quite an inopportune time, we don't really know whether there was any cancer in lymphs. So, the staging could be wrong, but hopefully this would not have changed the treatment plan.
Now the concern is that doctors may still remove her level 1 lymphs based on previous diagnosis, potentially causing un needed side effects. How do the surgeons know which lymphs need to be taken out? Also, what are the chances of lymphedema if her Level 1 axillary lymphs are taken out?
Cam the neoadjuvant chemo help save her lymphs?
B))Also, I have attached her CBC reports and Vitamin reports after the 5th day of 3rd AC cycle. Can you please let us know if the level of vitamins in her blood seems okay
Continuing from our last thread
http://www.healthcaremagic.com/AskDoctorInboxServlet?page=viewQuery&queryId=182718
A))I was looking at my Mom's previous reports (all of them attached)
1. Mammography - This was done on 15th January and it showed no abnormality to Axilla (Bilateral axilla are normal)
2. PET - This was done on 2nd Feb after the FNAC which led to an inflammation and infection and swelling of the entire left breast. The swelling was quite prominent. The PET scan found a few metabolically active Level 1 lymph nodes (Few discrete FDG avid lymph nodes noted at axilla level 1)
3. Ultra sound - This was done on 3rd Feb, a day after PET. The swelling was still there and unlike the mammogram done earlier, this ultra sound found swollen lymph nodes (most likely due to the inflammation) (report says - few enlarged lymph nodes are seen in the left axilla)
4. Ultra sound - We did this one recently to check the size of the tumor. The tumor has reduced a lot in volume (I am guessing ~ 90%). Also, it did not find any enlarged lymph nodes.
Now, since the PET was done at quite an inopportune time, we don't really know whether there was any cancer in lymphs. So, the staging could be wrong, but hopefully this would not have changed the treatment plan.
Now the concern is that doctors may still remove her level 1 lymphs based on previous diagnosis, potentially causing un needed side effects. How do the surgeons know which lymphs need to be taken out? Also, what are the chances of lymphedema if her Level 1 axillary lymphs are taken out?
Cam the neoadjuvant chemo help save her lymphs?
B))Also, I have attached her CBC reports and Vitamin reports after the 5th day of 3rd AC cycle. Can you please let us know if the level of vitamins in her blood seems okay
Brief Answer:
lymph node dissection required
Detailed Answer:
My answers
1. The treatment plan has been perfect and I don't think it would have changed if everything were the same but no nodes were seen on PET
2. We have to completely remove her level 1+2 axillary lymph nodes. If during surgery, level 1+2 nodes look suspicious then level 3 also. This decision is not based on PET. This is the standard surgery for breast cancer. Only exception is when the primary tumor is small AND there are no suspicious nodes in axilla AND a sentinel node biopsy is done along with upfront surgery. Sentinel node biopsy before neoadjuvant chemo in small tumors with no suspicious nodes is also acceptable. But, sentinel node not to be done in locally advanced primary tumor or suspicious axillary nodes (irrespective of neoadjuvant chemo). In these cases always level 1+2 +/- 3 axillary full dissection.
3. Lymphedema risk is around 30% but severe is about 5-10%
4. I can't see the blood reports or vitamins
Regards
lymph node dissection required
Detailed Answer:
My answers
1. The treatment plan has been perfect and I don't think it would have changed if everything were the same but no nodes were seen on PET
2. We have to completely remove her level 1+2 axillary lymph nodes. If during surgery, level 1+2 nodes look suspicious then level 3 also. This decision is not based on PET. This is the standard surgery for breast cancer. Only exception is when the primary tumor is small AND there are no suspicious nodes in axilla AND a sentinel node biopsy is done along with upfront surgery. Sentinel node biopsy before neoadjuvant chemo in small tumors with no suspicious nodes is also acceptable. But, sentinel node not to be done in locally advanced primary tumor or suspicious axillary nodes (irrespective of neoadjuvant chemo). In these cases always level 1+2 +/- 3 axillary full dissection.
3. Lymphedema risk is around 30% but severe is about 5-10%
4. I can't see the blood reports or vitamins
Regards
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
1. I have attached all the reports along with the CBC and Vitamins reports again. If you see Mammography 15th XXXXXXX it suggests normal lymphs. Why can we not have sentinel lymph node biopsy after neoadjuvant chemotherapy to look for traces of cancer. If the cancer has spread, sentinel nodes will have more cancer cells and if we don't find cancer cells there, what is the reason to believe axillary lymphs will have cancer cells.
2. What would be the difference between lymphedema and severe lymphedema. How is the quality of life affected with lymphedema which 30% of the patients get? Are there good rehabilitation centers in XXXXXXX for lymphedema?
3. Can we do something before hand to reduce the chances of getting lymphedema? Exercise etc?
3. Currently my and mom's biggest worry is lymphedema. At this age, compromising on the quality of life is a big concern, so we are looking at best possible ways mitigate the risks
4. Which is the best place to get breast cancer surgery in India?
5. This forum is great as we can have candid discussion with the doctors. Its difficult to have a discussion with the doctors we normally visit. General attitude is that if you are asking a lot of question, you don't trust your doctor, which I find a bit strange.
2. What would be the difference between lymphedema and severe lymphedema. How is the quality of life affected with lymphedema which 30% of the patients get? Are there good rehabilitation centers in XXXXXXX for lymphedema?
3. Can we do something before hand to reduce the chances of getting lymphedema? Exercise etc?
3. Currently my and mom's biggest worry is lymphedema. At this age, compromising on the quality of life is a big concern, so we are looking at best possible ways mitigate the risks
4. Which is the best place to get breast cancer surgery in India?
5. This forum is great as we can have candid discussion with the doctors. Its difficult to have a discussion with the doctors we normally visit. General attitude is that if you are asking a lot of question, you don't trust your doctor, which I find a bit strange.
Brief Answer:
See below
Detailed Answer:
My answers
1. You have attached all reports twice but not CBC and vitamins. or maybe some system fault. Talk to customercare please.
We do not advocate SLN after neoadjuvant as the false negative rate is high (SLN shows no cancer cells but if all nodes are removed, cancer is found). Please see this study which failed to establish the safety of this approach http://jama.jamanetwork.com/article.aspx?articleid=0000
2. In severe lymphedema there is pain and limitation of normal activities, hampering quality of life. In mild, there is just swelling but it is not causing any problems. Most cancer centers have some rehab services for lymphedema.
3. yes, there are ways to mitigate lymphedema. You can go through this nice site http://www.breastcancer.org/treatment/lymphedema/reduce_risk
4. There is no 'best' place because there are many good places. However, Dr XXXXXXX Badwe at TMH XXXXXXX has probably the highest experience. In XXXXXXX XXXXXXX Fortis, XXXXXXX Apollo are good centers.
Please let me know if you need any more clarifications.
See below
Detailed Answer:
My answers
1. You have attached all reports twice but not CBC and vitamins. or maybe some system fault. Talk to customercare please.
We do not advocate SLN after neoadjuvant as the false negative rate is high (SLN shows no cancer cells but if all nodes are removed, cancer is found). Please see this study which failed to establish the safety of this approach http://jama.jamanetwork.com/article.aspx?articleid=0000
2. In severe lymphedema there is pain and limitation of normal activities, hampering quality of life. In mild, there is just swelling but it is not causing any problems. Most cancer centers have some rehab services for lymphedema.
3. yes, there are ways to mitigate lymphedema. You can go through this nice site http://www.breastcancer.org/treatment/lymphedema/reduce_risk
4. There is no 'best' place because there are many good places. However, Dr XXXXXXX Badwe at TMH XXXXXXX has probably the highest experience. In XXXXXXX XXXXXXX Fortis, XXXXXXX Apollo are good centers.
Please let me know if you need any more clarifications.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Brief Answer:
reports ok
Detailed Answer:
The CBC and vitamin reports are fine. Lymphocytes bit low but acceptable. Same for hemoglobin.
Tumor markers in breast cancer are not recommended unless metastatic disease.
It is not a routine to repeat PET or CT/bone scans before surgery again if the patient has responded unequivocally.
Regards
reports ok
Detailed Answer:
The CBC and vitamin reports are fine. Lymphocytes bit low but acceptable. Same for hemoglobin.
Tumor markers in breast cancer are not recommended unless metastatic disease.
It is not a routine to repeat PET or CT/bone scans before surgery again if the patient has responded unequivocally.
Regards
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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