Information needed

[bhavika23]

I was detected with left breast cancer ER PR negative her 2 positive. 1 out of 22 lymph nodes was cancerous. But my first PET showed a lesion in rib (back) SUV 2.9. Doctors were unsure it is Metastic or due to some injury or prior sickness. After chemo lesion decreased to 1.8 with complete regression in metabolic activity. Still I cudnt get a clear answer wat it is. On Dr said single rib lesion is not Metastic ñ can b controlled by herceptin. One said lesion less than SUV 3 is not Metastic ñ herceptin will work. Now plz I need clarification wat this lesion cud mean ñ wat happens after herceptin stops. I am scheduled for 12 cycles of herceptin till now. Can this lesion form cancer?

[roxboxfox RadiationOncologist]

A Biopsy from this lesion would be the only ideal way to know if this is really cancerous or not.

No one on this planet can tell you for sure 100% if this is cancerous or not. We can all just give you our guesses and in our great medical judgement give you our opinions, this may be , this might not be , this could probably be , this possible may not be.........

The bottom line is no one really knows the answer: Its 50:50

If this is Metastatic: You would need Herceptin indefinitely which is a bit difficult to follow especially in Indian setup as you would be paying from your pocket, unlike the western setup where everything is free or the iinsurance company pays up honestly without causing fuss and distress to patients.

If this is Not metastatic : You would need Herceptin as per Standard Guidelines for 1 year (Total of 17-18 infusions).

Unfortunately, in your scenario, one will have to play watch and wait game, and perhaps perform scans on may be 6 monthly basis to monitor the Rib lesion, very closely.

If indeed this does grow, or its SUVmax does increase beyond 4 or 5, it would be reasonable to attempt a biopsy in the years to come, and possibly have this rib resected should this be the only site of spread of cancer.

But, its equally possible, that this is nothing and just a bone island, and your cancer is all cured and gone, and you are already cured of your cancer.

[bhavika23 in reply to roxboxfox]

But sir if I consider it not being cancerous then y did d lesion decrease after chemo ? Ñ God forbid if it is cancerous then herceptin shud b taken evry mnth or schedule will b changed?

[roxboxfox RadiationOncologist in reply to bhavika23]

If you have a bruise or any injury, why do you think this improves over a period of time, similarly once healing takes place the SUV may decrease, the drop is SUV from 2.9 to 1.8 is not any miracle or jaadu.

It does not have the same significance if the SUV max was 20 and came down to 1.9

If its cancerous it is metastatic technically Stage IV: Guidelines mention life long Herceptin till further evidence of progression

[sumeet_shah Administrator in reply to roxboxfox]

What would your opinion be, on radiating that isolated rib met?

[bhavika23 in reply to sumeet_shah]

Sir I talked to my onco...he said since we r nt sure wat lesion indicates...we take it as mets ñ treat with herceptin 17 cycles ñ a hormone tab. After stopping herceptin they will review aftr 3 mnths. If no changes well ñ gud but God forbid if it increases we radiate it. Now leaving to God whatever my future holds. Plz suggest is the line of treatment ok or shud there b ny changes. I asked for needle test too Bt they didn't agree for it. They said pray God that it's just an injury

[bhavika23 in reply to bhavika23]

By God's grace all other tests aftr 6mnth from surgery were fine. Dexa chest x-ray ultrasound echo .

[roxboxfox RadiationOncologist in reply to sumeet_shah]

Sumeet, I personally do not believe this rib lesion of SUV 2.9 to be metastatic.

One would ideally sit down in the MDT with the Radiologist, review the CT plates looking at the Bone window carefully and try to look for any malignant features...A radiologist should have a fair idea about this.... And will sway on this towards benign or malignant...

From an oncologists perspective, I would treat this exactly as this lady's Oncologist of offering STD treatments with Adjuvant Chemotherapy, she would need chest wall or Breast RT, Herceptin for one year and Hormone Therapy as well as we would normally do.

I would be extra vigilant and monitor this rib lesion via imaging and if any concerns...first I would seek tissue diagnosis and ask my surgical Oncologist for role of any rib resection if this is the only site of growing Mets after all STD Therapy.

A multidisciplinary approach in conjunction with radiologist, Oncologist and surgeon is vital in he management here.

[sumeet_shah Administrator in reply to roxboxfox]

Yes, agreed. Just wanted your perspective. Unfortunately, at many places, this MDT is lacking and both docs as well as patients barely have co ordination resulting in unnecessary stress for all.

[bhavika23 in reply to sumeet_shah]

Sir wat is MDT?

[sumeet_shah Administrator in reply to bhavika23]

MDT is Multi disciplinary Team. Like for example, for our patients, me as a Surgical Oncologist, Dr. Rohit as Radiation Oncologist and Dr. Ashish as Medical Oncologist, our colleague radiologists, we all sit together, discuss about the patient and take joint decisions. When not possible to meet, we co ordinate by emails.

[bhavika23 in reply to sumeet_shah]

Ok thnk u so mch sir for ur support.

[bhavika23 in reply to bhavika23]

Wat is ur opinion About my case?

[Imorsh]

Hi there, my mum has recently been diagnosed with the same. We havenot had PET scan but bone scan, liver and chedt scan prior to the operation. All appear to be clear. However, during operation all her lymp node except an ephical lymp node found to be metastic.

Could you please confirm your agreed treatement plan? Also, where are you buying herceptin from and how much is it?

Please advise