How are micromets found?

[Jackie07]

Hi,

I've read from several members signature or postings about 'micromets'. How are they found? Is PET scan able to pick up the signal? All the doctors I've seen seem to be confident about the PET scan result. But I wonder...

[Mary Jo]

I have been told that "micromets" cannot be found on any scan ~ CT or PET/CT (not sure about MRI but thinking that one also).

Mary Jo

[Becky]

I believe what you are seeing on our signatures (like Marejo's and mine) about micromets in the sentinel node. A micromet is a mass of cancer cells that is less than 2mm. They usually cannot be picked up by Pet/CT but these are in the sentinel node which is removed and dissected (in order to stage the cancer - ie: positive or negative nodes).

This is not distant micromets which cannot be detected until the tumor becomes larger (I can't remember the smallest mass PET/CT can detect - I want to say 1cm but I may be wrong on that).

[AlaskaAngel]

Sampling bone marrow is one way that has been proposed. I tried to find the original link for this but couldn't, so here it is:

Micrometastases often persist in breast cancer patients
Reuters Health
Posting Date: March 8, 2005
Last Updated: 2005-03-08 11:27:01 -0400 (Reuters Health)

NEW YORK (Reuters Health) - Despite undergoing surgery and receiving adjuvant therapy, most patients with early-stage breast cancer have bone marrow micrometastases up to 4 years later, according to a report in the March 10th issue of the International Journal of Cancer.

Dr. Martin J. Slade, from Imperial College London, and colleagues used a quantitative PCR (QPCR) technique they developed to look for transcripts of cytokeratin 19, a cancer marker, in the blood and bone marrow of 131 women with breast cancer, most of whom had node-negative T1 disease. These results were compared with standard immunohistochemistry findings.

All of the patients were treated with surgery and adjuvant therapy and had no evidence of metastatic disease on conventional scans.

About half of the patients had QPCR or immunohistochemistry results that indicated bone marrow micrometastases before surgery, the authors note. Of the 91 subjects who had repeat samples taken, 87% and 65% had evidence of metastatic disease at some point with QPCR and immunohistochemistry, respectively.

Systemic adjuvant therapy seemed to have an effect on residual disease. Among patients with residual disease before treatment or at 3 months, 32 of 44 displayed a drop in the CK19/ABL ratio and 15 of 24 showed a drop in cytokeratin-positive cells during follow-up, the authors point out.

"We have demonstrated that in a substantial proportion of patients, minimal residual disease persists using the techniques that we have developed, and that it is possible to monitor patients, preferably using both QPCR and immunohistochemistry, after breast surgery using bone marrow aspirates," the researchers conclude.

Int J Cancer 2005;114:94-100.

[mcgle]

AA

Forgive me if I have misunderstood, but are you saying that even those of us with clean nodes and negative vascular invasion are at risk of micromets?

Also, do micromets always lead to metastatic disease? I thought a strong immune system might deal with these before they created havoc. Or am I wrong to think this?

Scary stuff, however you look at it.

Mcgle (UK)

[Mary Jo]

Hello Mc....

Unfortunately, micromets are always a risk. Hence, the systematic treatment (chemo) for many of us. The larger the tumor the greater the risk. In my case, there was not vascular invasion and ONE micromet to one sent. node. I had a large tumor and of course it was her2 positive. So, the thinking is chemo and herceptin to kill anything that might be "out their" - if that makes any sense. I was given a PET/CT at diagnosis and there were no mets. I thought - whoosh, I'm safe BUT being a newbie at that time and after talking to my onc. realized all that means is that there is nothing 1 cm. or larger that could be detected.....so........not fool proof for sure.

That's why this disease is so freakin' frightening. We don't know what's going on "in their" and with cancer anything is possible. So we just live and let live..........do all we can................and pray for the best.

Love to you,

Mary Jo

[BonnieR]

I did not entirely understand the whole article. Maybe because I froze after reading the words "MOST patients...." in the first sentence.

[Jean]

Great Article and discussion.
when I was first dx. I knew next to nothing regarding all these issues (newbie ) like MaryJo..and many of us. After my surgery (about a month) I was reading about a trial of bone biopsey along with SNB because of this very issue. That early stagers have this feeling of being way out of the woods with a "so called clean SNB" and treatment is determined by the node status along with tumor size. etc.

When reading about the bone biopsey trial at Cornell
(where I had my surgery) I was a bit annoyed that the
surgeon did not even tell me about a trial that certainly
I was a strong candidate for.

Like many other issues in the real world of business
and lets face it "cancer" is a business, politics was part of the issue at hand. The dr. who was in charge of the trial was not my surgeon and it appears that these two
surgeons are both major players at the hospital.

Lani has posted many articles on this issue of bone biopsey along with SNB. Why is this biopsey not part of the practice is a mystery to me. We are still in the infant stages of treatment with early stage bc. Much more research is needed. I am annoyed that many women still today who are early stagers may hear, "You are lucky...you caught it early" This is just nonsense!
There is so much lurking - dormant cells that could or may be sitting in the blood rich enviorment of our bones.
I had requested to have a bone biopsey performed and could not get it done not because of insurance reasons, my insurance would cover it/but the hosptial rules and regulations.

That is one of the reasons I fought so hard to gather additional informtion so I could make the best treatment decisions. It is a shame that any woman has to fight so hard to gather information to make treatment decisions. I had to fight for Oncotype DX...it was not
bible at the time...if I had not gone to see Dr. Slamon
I may never have had herceptin. As Dr. Slamon told me back then prior to herceptin being approved by our FDA..."all women with Her2 shoud be treated with herceptin" and at that time he advised chemo also. Maybe one day in the near future chemo will not be a part of the early stage treatment with herceptin if a bone biopsey is performed to determine what is lurking. Jury is still out on so many issues. I am thankful that herceptin is now approved for all Her2 patients.
But back then Dr. Slamon knew!

Some good news to share with all. My sister came to visit from Florida and brought a friend with her. This lady was dx. with bc 6 yrs. ago and was ER- PR- Her2 +++ stage 1...did not know what it all meant. Her husband did lots of research for her. She was the type of lady
that did not want to know, (and I respect that fact) the dr./and/hospital where she was having her surgery etc. offered her herceptin. Her husband advised her that she should try this new drug from what he was reading he thought she should. She did not even understand the importance of herceptin she told me. She is doing great with NED....

We need more research, trials, money, attention,
information and education.

Okay that's all folks!
Jean

[AlaskaAngel]

Mcgle, your understanding is correct. Until it is understood why 6 out of 7 women do not develop breast cancer, and then how to change our circumstances so that 7 out of 7 women do not develop breast cancer, there are no sure bets about treating it. However, having negative nodes and no LVI are two characteristics that do make both micromets and recurrence less likely, as well as recurrence less imminent.

That includes those who do chemotherapy and those who don't. There are those who do treatment and do well for years. There are those who lose their hair, have projectile vomiting, have neurologic effects not only during chemo but permanently, affect their immune system, and yet recur early because the chemotherapy never worked for them. There are those for whom the toxic therapy may actually cause recurrence. There are those who do chemotherapy and develop myelodysplastic disease. There are those who do chemo plus monoclonal antibody and who have recurrence because none of the treatments ever worked for them, or because eventually it stopped working.

There are those HER2's who were diagnosed before a monoclonal antibody was available and who are now past the time of greatest risk for recurrence. The protective effect of chemotherapy drops sharply around 5 years out.

Those who had no LVI and no positive nodes and who never had toxic treatment do still have some risk for recurrence, just as do those who did do toxic treatment; the trade-off is that since they never did toxic treatment, they never damaged their immune system. This may be of greater advantage for them in regard to vaccines now in development as well as other treatments.

It is a matter of choice either way, and impossible to know with absolute certainty what will work for anyone.


AlaskaAngel


(Negative SNB and no LVI, 6+ years out and past protective effect from CAFx6 IF there was any, but with damage to immune system; never had a taxane, never had dose dense, never had trastuzumab, and still NED)

[AlaskaAngel]

Mcgle, your understanding is correct. Until it is understood why 6 out of 7 women do not develop breast cancer, and then how to change our circumstances so that 7 out of 7 women do not develop breast cancer, there are no sure bets about treating it. However, having negative nodes and no LVI are two characteristics that do make both micromets and recurrence less likely, as well as recurrence less imminent.

That includes those who do chemotherapy and those who don't. There are those who do treatment and do well for years. There are those who lose their hair, have projectile vomiting, have neurologic effects not only during chemo but permanently, affect their immune system, and yet recur early because the chemotherapy never worked for them. There are those for whom the toxic therapy may actually cause recurrence. There are those who do chemotherapy and develop myelodysplastic disease. There are those who do chemo plus monoclonal antibody and who have recurrence because none of the treatments ever worked for them, or because eventually it stopped working.

There are those HER2's who were diagnosed before a monoclonal antibody was available and who are now past the time of greatest risk for recurrence. The protective effect of chemotherapy drops sharply around 5 years out.

Those who had no LVI and no positive nodes and who never had toxic treatment do still have some risk for recurrence, just as do those who did do toxic treatment; the trade-off is that since they never did toxic treatment, they never damaged their immune system. This may be of greater advantage for them in regard to vaccines now in development as well as other treatments.

It is a matter of choice either way, and impossible to know with absolute certainty what will work for anyone.


AlaskaAngel


(Negative SNB and no LVI, 6+ years out and past protective effect from CAFx6 IF there was any, but with damage to immune system; never had a taxane, never had dose dense, never had trastuzumab, and still NED)

P.S. Apologies for the double post -- Hopefully this will "land" in the thread as a response to mcgle's question.

[mcgle]

Thanks for your responses, ladies.

Mary Jo - I am sorry you had one micromet to the sentinel node, but suspect you would have had chemo anyway owing to the size of your tumour.

Bonnie - yes, I froze, too!

Jean - apart from negative lung xray at dx, have never had any scans apart from ultrasounds; neither is the Oncotype test available here in the UK. So all I can do is to keep my body in the best possible condition through sensible eating and exercise.

AA - thanks for your explanatory post. Feel a bit better now. Your own history is very encouraging for those of us further down the line. Just sorry you had to endure chemo, maybe unnecessarily. I was told that herceptin would have been of negligible benefit to me, being weakly HER2+. So yes, I think you are right when you say, ' ... impossible to know with absolute certainty what will work for anyone.'

Mcgle (UK)

[Jean]

Mcgle,
Yes, your statement "Scary Stuff" is true.
That is why research is so vital, understanding the enemy is one way to defeat the enemy, and cancer is everyones enemy.

There are combinations of information that I believe are helpful to women when making treatment decsions.
First of all the node status, while negitive nodes are always favorable - that is not the only answer. Another important feature to study is the KI-67 level as Dr. Slamon explained it is a very important feature when making treatment choices. In my case it was high, along with highly positive for Her2. Each person has to make their own treatment choices based on as much medical information you can have tested to establish what is "SPECIFIC" for you and your bc. Certainly everyone wants the appropriate therapeutic intervention.

Like anything else one shoe may not fit all feet that are the same size. It is important to review all of the pathology reports, test, staining, to determine your own
risk, if it be high, medium, or low. Even then no one is 100% certain. Why do some patients reject herceptin?
We do know that for the majority it is a life saving drug.

It is my belief that the new stats from early stagers who have had treatment will display very compelling information for those with Her2. Having this dx. just a few years ago was bitter news. Now with the new drugs and herceptin I believe we can begin to see some light at the end of the tunnel.

Remember we are all unique and trials give results for the majority. That is why medicine is an art and not just a science.

All we can do is obtain as much important information that helps define treatment strategies.
Below I have linked an interesting article on bone marrow and micro mets...

http://jcp.bmj.com/cgi/content/full/61/5/570

Regards,
Jean

[AlaskaAngel]

Very nice current article, Jean. It shows very well how a term that gets casually thrown around like "micromets" is actually fairly complicated.

AlaskaAngel

[Jackie07]

Ditto to that. Thank you, guys.