For Tom

[Lani]

I cannot remember all the particulars regarding your mother's breast cancer, but I do remember you experienced great consternation trying to get the doctors to recognize and act on her inadequate surgical margins. I do not remember if she received radiation therapy, but maybe this article will prove
useful (and reassuring) to you if she did:

4 August 2006
Surgical margin re-excision requirement defined
Not all breast cancer patients with non-negative surgical margins require further surgery, US researchers say.

Gary Freeman, from Fox Chase Cancer Center in Philadelphia, Pennsylvania, and colleagues examined the impact of re-excision on 1044 women with stage I or II disease, a close (? 2 mm) or positive margin, and who were scheduled for radiotherapy.

The patients were divided into three groups according to whether they did not undergo further excision (group 1, n=199), underwent re-excision and were free of tumor (group 2, n=546), or had residual disease detected on re-excision (group 3, n=299).

Following-up the women for a median of 6.7 years, the 10-year rate for local control in groups 1, 2, and 3, was 95%, 94%, and 94%, respectively.

Examining data from group 2 and 3 patients further, the researchers found that a positive finding on re-excision was predicted by an initial positive tumor margin, positive lymph nodes, stage T2 disease, and a positive or unknown extensive intraductal component (EIC) status.

Specifically, the likelihood of positive residual disease was ?15% in node-negative patients with a close initial margin without EIC and stage T1 or T2 disease, rising to 30–40% in those with an additional poor prognostic factor of positive margins, lymph nodes or EIC.

For patients with all three poor prognostic factors, the risk of disease on re-excision rose to over 80%, Freeman et al state.

"Our findings suggest that re-excision produced additional diagnostic information, distinguishing between a subset of women at extremely low risk of developing local recurrence (Group 2, 5%), and a subset at slightly greater risk of recurrence (Group 3, 9%)," the team summarize.

They believe that the policy of re-excision in all patients without a 2 mm or greater margin led to unnecessary surgery in two-thirds of patients who had no residual disease.

The authors therefore conclude: "The necessity of re-excision for close or positive margins needs to be carefully weighed according to the likelihood of finding residual disease in a re-excision specimen, its effect on breast cosmesis, and the magnitude of risk reduction it could afford for local recurrence after radiotherapy."



Int J Rad Oncol Biol Physics 2006; 65: 1416–1421

http://www.redjournal.org/article/PI...03695/fulltext
© 2006 CMG

[Tom]

Hi Lani. Sorry I didn't see this and respond sooner. I swear my eyesite is going south on me.

The story with Mom was this: Her surgeon decided to move ahead with her lumpectomy without doing a biopsy first. I was OK with that, and I wanted the thing gone as soon as possible. We had discussed the "likely" nature of the tumor, and I was ASSURED it would be an estrogen+ tumor, and that Mom would have it removed and need only to take Tamoxifen afterwards. I was even strongly discouraged from having her go through rads, as it would be "inconvenient" on both of us, and unnecessary. It was suggested that if she had a local recurrence, we would simply have more surgery. I planned on rads against the surgeon's recommendations, as I knew that rads would drop her local recurrence chances down form 40% to 10%.

During the surgery, the first margin was found to be dirty, and the syrgeon went back for another pass against the chest wall. After the surgery, I asked about the results of the SNB, and was told that none was done, but that the one enlarged node was taken instead, in order to avoid unnecessary comorbidities of more extensive resection. I was very upset about that, but was again reassured that the case was simple and that I should not worry.

Then of course, came the pathology report "stick in the eye" some days later, revealing the HER2+, ER-, PR- status of the malignancy. I was phyiscally ill when I got the news. Still, I was sent off to the oncologist with a report that stated Mom's status as "clear margins and NEGATIVE nodes". How the hell could you say someone had NEGATIVE nodes when you only looked at one, and it wasn't even identified as the sentinel node?

Eight months later, I discovered enlarged nodes in Mom's axilla, and insisted on a biopsy of them, Of course, they were found to have cancer in the ones sampled. I again insisted that an axillary dissection be performed, against the advice of the same surgeon. A level II axillary dissection was done, resulting in a 12/20 positive node finding. I was furious. All involved agreed that the micrometasteses were there ALL ALONG, but were missed from the get go. Back for more rads we went, as the earlier rads had not covered all of the involved nodes. Then I had to beg for early Herceptin.

The bottom line of this tale (not to beat a dead horse) was that had Mom had the appropriate staging, SNB, the micromets would have been found, and the appropriate rads could have been delivered, quite possibly knocking down the cancer at it's early stage of spread. The surgeon apologized to me, stating that "maybe we ( I guess she had a mouse in her pocket) hadn't done the best thing eight months earlier". THEN, she says that she believed the outcome would have been the same even if we HAD done the SNB. That was the most blatent CYA I have ever been privy to in my life.

Anyway, here we are much later, after two surgeries, two rounds of rads, and a year of Herceptin, waiting to see what shoe drops next, as Mom's Herceptin was stopped a month ago due to declining LVEF. We go next week to see what to do next. This all proved that good planning, and proper staging can save lives and reduce morbidity related to surgery and other forms of treatment.

Tom