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Hmm, 'can't figure out how to select out your words, Tom, and reply to your points one by one. When I choose "reply with quote", I can't see the quote. Anyway....
I don't know that lymphatic invasion precedes vascular. Do you have evidence to support that? How then to explain distant mets when lymph nodes are not involved? Again, I think that lymph node involvement is just a convenient and obvious marker of metastatic abilities of that particular cancer, an ability that not all cancer seems to have. But absence of lymph node involvement yet later distant mets doesn't mean that axillary involvement was necessarily missed, does it? The axilla could indeed be clear (as opposed to involvement being missed), and the surgical margins be clear, yet the cancer could have moved into the bloodstream before surgery and some of those cells could have found safe haven in the site of eventual mets. How they do that, how to know which cancer CAN do that, and how they evade tx there is the mystery. One of the mysteries.
As for removing the tumor and/or all the cancer cells being important to prognosis - yes, it's important to remove the primary, but the picture gets muddier when trying to prove the importance of removing cancer in lymph nodes. Logic tells me that should be important, but there's not much research to support it. I've know women who have declined axillary dissection even when there was clinically-evident lymph node involvement there, if the nodes shrank during neoadjuvant chemo. Their oncologists could not provide evidence that removing those involved nodes would change the outcome.
I think (hope) that what we're discussing about margins and lymph node status will become moot, as far as using the information prognostically or predictively. I hope that soon we'll look mostly at cell characteristics and from that will know the degree of threat of distant metatastatic potential of each tumor and be able to treat it accordingly, and with the best treatment for that particular tumor. But we're not there yet.
The bit about removing the primary even with concurrent extensive distant mets is so intriguing. There's got to be more to it than simply tumor load, because we know that in women with extensive distant mets (who had the primary removed at primary diagnosis), there is rarely an advantage to doing surgery to decrease the tumor load (unless it's one isolated and accessible site) and that the cancer responds (or not) to the treatment pretty much regardless of tumor load (ie, many large lung mets may shrink to nothing, just as a few small single ones would do).
So many questions yet to answer. Interesting discussion - thank you!
Debbie L.
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