Why some slow tumors go to nodes (and vice versa)?

Leighku

Just curious why some large (even aggressive) tumors do not move to nodes and some quite small tumor of low grade do? I had 3 tumors, multi centric, largest put me at stage 2, grade 3, super high ki-67% 87!!!. I did have cells in my lymph vessels which gave me positive LVI but none in my 3 nodes. Have a friend with just teenie tiny 6mm tumor and micrometers to one node who less than 2 years out is stage 4. Have a new friend with just tiny 7mm tumor, grade 2, low oncotype (no chemo) that had micrometers in her first node. I'm curious how the slow moving ones can make it there and some fast moving ones don't. I know I am higher risk than most stage 2s (with my subtype) due to LVI, 3 tumors and high KI-67...I know its possible they flushed right by the nodes but doc suggested my immune systems worked hard to get them on their way there. I like the thought but was wondering if anyone else's Onc shared any theories or thoughts on this.

Thanks.

dlb823

Leighku, in addition to not-yet-understood genetics, which I think is a huge factor in the individual development of each of our bc's, the other factor seems to be the microenvironment in which cancer metastasizes. Here are a few articles on the subject, which I've heard is a new, "hot" topic at oncology meetings. Deanna

http://www.sciencedaily.com/releases/2015/05/15052...

http://www.sciencedaily.com/releases/2015/08/15081...

http://www.sciencedaily.com/releases/2015/03/15031...

crazystupidbreastcancer

There's a lot of factors that goes into how/why the tumors spread to lymph nodes. I'm not sure why some of the larger tumors are slow growing and lazy. And why some of the smaller tumors are aggressive and rapid spreading. My tumor was 1.2 cm, at the time of my diagnosis. When I had my PET scan a week later, one of my lymph nodes lit up. And the PET scan estimated the tumor in the lymph node was around 2 cm. Provided my Ki-67 was 45% and my tumor was grade 3, those are indicators for an aggressive tumors.

Sjacobs146

I'm guessing that my Cancer made it to my lymph node due to proximity, my lumpectomy and SNB scars are about an inch apart. I plan to read the articles referenced in Deannas post for mor info.

ruthbru

I was just talking to a friend about that very question. Her family is in a research study because quite a few members have had a variety of cancers, each with very grim prognoses; so there must be some sort of genetic propensity to cancer BUT (so far) each family member has had a complete response to his/her treatment and once it was completed has never had a recurrence (my friend had an advanced ovarian cancer 35 years ago at the age of 21, her sister had a Stage III BC so large and close to the chest wall that they didn't dare operate until after chemo.....when they did the surgery, there was no left tumor to be found!). So researchers are also trying to find out what about their makeup makes treatment so successful.

windingshores

Leighku was your LVI focal or extensive, and did you have an Oncotype done?

I was told that 30% of grade 3's have low Oncotypes. The clinical data and Oncotype don't always match up.

sas-schatzi

Ruth, can you find out whose studying your friend? Been trying to find someone to study my family.

ruthbru

She just took off on a vacation but I will make a note to ask her when she gets back.

doecontardo

Hi there, unfortunately I don't know all the medical terms but will tell you what I know. Oct 13, 2015 I underwent a bilateral lumpectomy for estrogen induced breast cancer and a sentinel node dissection. My tumors in each breast were 9mm..yes odd they were the same size. 5 nodes were removed on the left side and came back negative. 1 node was removed on the right and came back positive. Originally I was told before the node results that all I would need is radiation after the surgery but now it was suggested that I have chemo and then radiation. I am 50 yrs old and had a hysterectomy 5 yrs ago and have started going thru menopause. Is chemo absolutely necessary or could I do hormone therapy and radiation only....I am sooo overwhelmed

marion55

im the same i have cells in the lymph needs chemo to kill them off

debiann

Don't remember where I read this, but the explanation was basically that low grade tumors are slow growing and may be present for many years before they are noticed. This allows more time for cells to escape. 

Don't know how accurate this theory is, but it makes sense.

Molly50

I had a 2.1 CM tumor oncotype 13, extensive LVI and 2 positive nodes. One node was 1.5 CM tumor and the other was micromets. No chemo for me due to low end of moderate oncotype and my Ki-67 was on the low side as well. doecontardo, you might want to get a second opinion. Did they do an oncotype DX on you?

Moderators

doecontardo, welcome to BCO, and sorry you have had to join us. We second what Molly50 says, that a second opinion may be important to help you decide.

jojo9999

doecontardo,

as Molly also suggests, you might ask your doctor to do OnctotypeDX testing - it is done for hormone + cancer. Although originally used only for node negative bc, it is now widely used when there are 1-3 positive nodes. There are lots of women (myself included) who had positive nodes but skipped chemo due to low oncotype scores.

Englishmummy

@ doecontrado - I third or (or 4th?) the oncotype, see if they will do both sides. I somewhat regret not having both done but my left was tubular with low ki67- I am left wondering though. Anyrate, I went with what was advised. BTW, there is a thread for bilateral BC

https://community.breastcancer.org/forum/109/topic...

Come over and say 'hello'

Edited for spell check error on name

Englishmummy

That's interesting, DebiAnn - my onco told me, in general : slow growing, indolent cancers are less likely to seed and that faster growing, more aggressive tumours are likely 'messy' , more likely to be on the move? Your research makes sense, in that low grade lesions can have recurrences, far down the line......I find this particular topic really interesting, especially with the initial results from the TailoRx trial.

doecontardo

Thank you everyone, I am scheduled for a bone scan this week and still waiting for my chemo oncologist appt. What is this OnctotypeDX testing? I will be going for genetic testing? Is it the same thing? Chemo frightens me as I have a couple of friends who have had it and have later experienced cancer elsewhere in their body. Is it really necessary to have chemo for microscopic cancer cells when you are treating those cells with radiation already.

debiann

doecontardo, radiation is a treatment to prevent local recurrence. It will only zap cells that have escaped to the breast and lymph node area. Chemo is a systemic treatment because it circulates through your entire body to kill tiny stray cancer cells.

I have often wondered the opposite, if you are doing chemo why do you also need radiation?

BarredOwl

Hi Doecontardo:

Genetic Testing of the kind you will be having is a different thing from Oncotype DX testing.

"Genetic testing" is performed on a sample containing normal cells (e.g., blood) to determine if you carry a mutation that confers a genetic pre-disposition to cancer. (The methodology entails extensive genomic DNA sequencing and may also include an assessment of certain gene rearrangements.)

In contrast, Oncotype DX for "invasive" disease is performed on a sample of tumor cells and assesses the levels of gene expression (not the DNA sequence) from 16 cancer-related genes and five reference genes. (The methodology used is quantitative "RT-PCR" (reverse-transcriptase polymerase chain reaction) which looks at transcription.)

In some patients with invasive disease, the information from the Oncotype DX test is used to assess "chemotherapy benefit and the likelihood of distant breast cancer recurrence" as an aid in decision-making about chemotherapy. Note that the test assumes that the patient will be receiving endocrine therapy (e.g., aromatase inhibitor in post-menopausal patients) in all cases.

http://www.oncotypedx.com

Oncotype DX is used in node-negative and certain node-positive patients. For a summary of eligibility see the chart at the bottom of this page:

http://breast-cancer.oncotypedx.com/en-US/Professi...

Your profile indicates Stage IIB, with1 positive node, suggesting that your TNM stage is T2, N1, M0, where a T2 tumor is greater than 20 mm (2 cms) but less than or equal to 50 mm (5 cms) in greatest dimension. The chart indicates that pT2, N1 (hormone-receptor positive, HER2-negative) patients with 1-3 positive nodes are formally eligible for the test.

However, I checked the National Comprehensive Cancer Center (NCCN) guidelines (Professional Version 3-2015), and for some reason, they do not seem to mention the Oncotype DX test for tubular histology. I do not know why that is; perhaps tubular histologies are not widely represented in the relevant clinical studies? In the absence of Oncotype DX, the decision of whether or not to add adjuvant chemotherapy to adjuvant endocrine therapy in node-positive tubular disease would be made on traditional criteria.

To be certain, please ask your medical oncologist about the Oncotype DX test, and whether it could provide useful information in your case or not.

BarredOwl

doecontardo

Well I'm back....oncotype is not offered here in Canada and a cost of $3000 if i want to get it done in the States.

This is where I stand now. I will give you some background first...in 2010(age 45) i had a partial hysterectomy..uterus removed... in 2015(age 50) i had my bilateral lumpectomy(9mm ea) and sentinal node dissection with 1 node positive.

I have decided not to do chemo as my bone scan came back clean and my ultrasound of internal and abdominal came back no signs of cancer. As well, I have a small aneursym in my head that has been monitored for 12 yrs now and is stable with no growth. After conversing with a Dr in Europe over xmas he advised that the risks of chemo especially with an aneursym are far more dangerous than any benefits the chemo may have for me. I start radiation Jan 18, 2016 3 weeks on my left breast, 5 weeks on right breast and all lymph nodes on right side. Hormone Therapy-Tamoxifen to follow after radiation.

My question is..since my cancer is estrogen induced would it benefit me to have my ovaries removed ...I have been going thru menopause for a couple of years now....and not go on the Tamoxifen(which I haven't heard many positive things about). Very confused because my medical oncologist gives me no other options other than chemo and I am not having a good experience at my cancer clinic. He doesn't seem to like when I ask questions. Very Stressful

Can you help me?

PS I am having genetic testing done in March 2016....requested by my radiation oncologist...not my medical oncologist.

Brutersmom

I had Invasive micropapillary CA 1.7 cm. I was told I had a very high risk for it being found in my lymph nodes. Nothing was found in the lymphnodes. I don't think anyone really knows why. Just my opinion.

BarredOwl

Hi Doecontardo:

You said you decided not to do chemotherapy, and that tamoxifen was recommended. You are wondering about possible ovary removal and not going on "the Tamoxifen (which I haven't heard many positive things about). Very confused because my medical oncologist gives me no other options other than chemo."

Tamoxifen is not "chemo". It is "endocrine therapy". My comments below are based on the assumption that you meant to say that your MO is only offering the drug tamoxifen as endocrine therapy, and he has not discussed any other possible options for endocrine therapy with you, such as oophorectomy (ovary removal).

This may reflect that he thinks tamoxifen is the best choice for you, and it is a reasonable option for many women. He may not believe that your diagnosis merits a more intensive treatment than tamoxifen alone. However, you would like more discussion about it, including other possible options and associated risk/benefit, so that you can make a more informed decision about what is the best endocrine therapy for you (with tubular histology, but 1 positive node, and not receiving chemotherapy). Please ask for more information (now or after the genetic test results come in). If he is not receptive to your questions (or if you would like a second opinion), please look for another MO who will take the time to address your questions and concerns, provide more information and advice, and help you decide.

I have no medical training, so the following discussion is for information only. Please confirm all information below with your MO and seek current, case-specific expert professional advice from your MO about what the best endocrine therapy for you would be.

As noted above, "chemotherapy" (which you chose not to take) and "endocrine therapy" (e.g., tamoxifen or an aromatase inhibitor) are different types of interventions. A person may receive endocrine therapy, but not receive chemotherapy.

As far as I can tell as a layperson, the recommendation for some type of "adjuvant endocrine therapy" is within the NCCN guidelines for a person with your type of disease. Then the question becomes: What type of adjuvant endocrine therapy would be best for you?

You mentioned you are 45 and "have been going thru menopause for a couple of years now." I understand this to mean you are peri-menopausal, have not yet achieved true menopause (12 or more months without a period), and are currently considered "pre-menopausal" (Confirm this with your MO)

Radiation begins Jan. 18 for at least 5 weeks (if the left and right regimens are concurrent). That takes you to Feb. 22, after which your MO recommended tamoxifen.

Genetic testing will be done in March, based at least in part on having bilateral disease at age 45. If the results were positive for certain pathogenic mutations (for example, BRCA1), it may be appropriate to consider oophorectomy (ovary removal) at that time. Thus, your genetic test results could inform your decision-making about a possible oophorectomy.

Typically, endocrine therapy is also prescribed to post-menopausal women (including those who have received an oophorectomy). This is because tissues other than the ovary can make estrogen (e.g., adipose (fat) tissue). If you removed your ovaries, you would be considered post-menopausal, but under the guidelines such such patients are still offered tamoxifen (to block the action of estrogen) or an aromatase inhibitor (to block the production of estrogen from other tissues).

You might consider trying the tamoxifen alone until you have the genetic test results back. That would give you some information about how well you tolerate tamoxifen. If the genetic results are good, you might decide to stay on the tamoxifen if you are tolerating it well. Or you may still wish to learn about other more intensive approaches to endocrine therapy and whether you are a good candidate for these.

The choice between tamoxifen alone and other more intensive approaches is a complex risk/benefit analysis, that must be made with your MO in light of your risk of local and distant recurrence, menopausal status, and overall health and presentation. Tamoxifen, aromatase inhibitors, and the drugs used to induce ovarian suppression have different side effect profiles. Oophorectomy has different health impacts. You can ask your MO (and/or another MO) to explain the more intensive approaches, their associated side effects, and obtain his opinion about whether your diagnosis merits more intensive treatment than tamoxifen alone. If your MO is not responsive to your questions, please consider seeking advice and/or a second opinion from another MO.

In general, initial endocrine therapy options include:

Pre-menopausal:

(a) Tamoxifen alone; or

(b) Tamoxifen with added Ovarian Suppression (to suppress/shut down ovarian function, e.g., with a second drug); or

(c) Ovarian Suppression (OS) plus an Aromatase Inhibitor (AI) (in pre-menopausal women, OS is required with an AI to shut down ovarian function; using both is intended to stop estrogen production from all sources)

(If oophorectomy is received, see post-menopausal options)

Post-menopausal (this includes patients whose ovaries have been removed by oophorectomy)

(a) Tamoxifen; or

(b) Aromatase inhibitor

You could ask your MO now or you may await the genetic test results in case they change the landscape. Again, please confirm all information with your MO and seek current, case-specific expert professional advice from your MO about what the best endocrine therapy for you would be.

BarredOwl

BarredOwl

Doecontardo:

You may also be interested in this thread, to learn more about the more intensive options for pre-menopausal women:

https://community.breastcancer.org/forum/78/topics...

Keep in mind that your diagnosis may differ, and what is recommended to others may be different from what is best for you.

BarredOwl

Pilgrim64

hi jojo, my story is similar to yours . Onco=14, they said no chemo. How are you doing now that it has been a year

cp418

BarredOwl - EXCELLENT reply/post!!