Treating Isolated Bilateral Axillary Lymph Node Positivity?
Treating Isolated Bilateral Axillary Lymph Node Positivity?
What would you recommend for a 44-year-old woman with bilateral axillary lymph node positivity? Chest, pelvis, and abdomen are clear on CT, and mammogram is negative. Stains excluded small cells and pathology favors poorly differentiated adenocarcinoma. She has no clinical signs or symptoms. Other than a maternal aunt who had breast cancer in her 70s, she has no other related medical or family history. Does it make sense to treat her at this point? If yes, what would you suggest?
This 44-year-old woman has bilateral axillary lymph node positivity with a clear CT of chest, pelvis, and abdomen, and a negative mammogram. Histologic studies have excluded a small-cell cancer, and the pathology has been said to favor a poorly differentiated adenocarcinoma. The patient has no clinical signs or symptoms to direct one to a primary source of disease. Family history is positive for a maternal aunt with breast cancer in her 70s.
In my view, the pathologic investigations on this patient are incomplete. There is no comment on stains that might more strongly suggest breast cancer. In particular, what are the results of estrogen- and progesterone-receptor testing? This testing is crucial, because if the patient is ER- and/or PR-positive, then the disease is likely breast cancer and hormonal therapy would be appropriate. One might look at a breast MRI to further rule in or rule out a primary breast cancer, but the performance of ER and PR assays is most important and should never be neglected in a situation such as this.
My other thoughts regarding pathologic investigation involve ruling in or ruling out the possible diagnosis of lymphoma, which would require very different treatment. Bilateral lymphadenopathy in a patient this age could be related to Hodgkin's disease. Is it certain that there are no supraclavicular or neck nodes? Are further biopsies and histologic investigations warranted?
It is a maxim of oncology that the diagnosis is paramount. In my view, the histologic diagnosis has not been adequately explored at this point in time, and a more complete work-up must be carefully done before further decisions can be made.
What would you recommend for a 44-year-old woman with bilateral axillary lymph node positivity? Chest, pelvis, and abdomen are clear on CT, and mammogram is negative. Stains excluded small cells and pathology favors poorly differentiated adenocarcinoma. She has no clinical signs or symptoms. Other than a maternal aunt who had breast cancer in her 70s, she has no other related medical or family history. Does it make sense to treat her at this point? If yes, what would you suggest?
This 44-year-old woman has bilateral axillary lymph node positivity with a clear CT of chest, pelvis, and abdomen, and a negative mammogram. Histologic studies have excluded a small-cell cancer, and the pathology has been said to favor a poorly differentiated adenocarcinoma. The patient has no clinical signs or symptoms to direct one to a primary source of disease. Family history is positive for a maternal aunt with breast cancer in her 70s.
In my view, the pathologic investigations on this patient are incomplete. There is no comment on stains that might more strongly suggest breast cancer. In particular, what are the results of estrogen- and progesterone-receptor testing? This testing is crucial, because if the patient is ER- and/or PR-positive, then the disease is likely breast cancer and hormonal therapy would be appropriate. One might look at a breast MRI to further rule in or rule out a primary breast cancer, but the performance of ER and PR assays is most important and should never be neglected in a situation such as this.
My other thoughts regarding pathologic investigation involve ruling in or ruling out the possible diagnosis of lymphoma, which would require very different treatment. Bilateral lymphadenopathy in a patient this age could be related to Hodgkin's disease. Is it certain that there are no supraclavicular or neck nodes? Are further biopsies and histologic investigations warranted?
It is a maxim of oncology that the diagnosis is paramount. In my view, the histologic diagnosis has not been adequately explored at this point in time, and a more complete work-up must be carefully done before further decisions can be made.
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