Breast Cancer-8

BREAST CANCER PART-8

Welcome to part 8 of educational series on breast cancer. In seventh part, we learned about evaluation of an early stage breast cancer.

Question: Many patients in India are diagnosed in advanced stages. Is this limited work up sufficient for them?

Answer: You are right. A large number of our patients come in with large tumors, and/or obvious axillary nodes. Most of these patients would be classified as Locally Advanced Breast Cancer – LABC, i.e. stage 3. These patients need all the tests noted for early stages. In addition, they need tests to make sure that they do not have metastatic disease already. Such additional work up includes preferably CT scan of chest and abdomen, or at least an abdominal sonography, bone scan. Any symptomatic area should be evaluated further e.g. neurological symptoms or headache should be evaluated with MRI of brain.

Stage 4patients, or those with established metastatic disease need tests to establish total tumor burden i.e. all the sites where tumor has spread, and to decide areas which need priority treatment. e.g. if there are brain metastases, first treatment is generally directed to brain. Similarly bone scan positive sites need x-rays to see if there is imminent fracture risk, especially important for weight bearing areas. PET scan is increasingly being used in this scenario. Tumor markers are also helpful in such a case, as they allow easy follow up e.g. CEA, CA 15-3, CA 27-29 (last is not easily available in India).

Of course, ER/PR/Her-2 status are very important to check, if not known from past, or if relapse is after many years.

Que: Thank you Dr. Shah. So, most of the evaluation is Radiological, trying to determine stage and spread of disease.

Ans: Yes, but do not forget the importance of pathology evaluation. Even before surgery, it is very important. A good biopsy is necessary to determine histology, grade, neurovascular invasion, and ER/PR/Her-2 status. Since patients with locally advanced breast cancer are treated with preoperative chemotherapy, detailed pathology evaluation is important presurgery. After surgery, this evaluation may not be feasible in many cases. For this reason also, FNA should not be used in LABC evaluation, rather a trucut or wedge biopsy.

Importance of a good histopathologist cannot be overemphasized. This is even more important with newer methods like IHC. Even in US studies, there is a 20% discordance rate (results not matching) between community hospitals and university hospitals for ER/PR/Her-2 tests. Since these are crucial tests in evaluating therapy options, they should be performed only in quality, high volume centers. No other tests e.g. ploidy, or S phase fraction are useful in clinical practice, and need not be routinely tested for. FISH testing can be used if Her-2 test is equivocal by IHC.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Ahmedabad. drchiragashah@gmail.com
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001 www.shyamhemoncclinic.com