Tumor growth after neo adjuvant but before surgery - more chemo?

LizSei · November 2012

(also posted on Chemo board - sorry if I'm not supposed to post in two places)

My friend had a 6cm x 9cm IDC lump and at least 1 positive node at diagnosis (biopsy) and the surgeon felt it was likely Inflammatory as well (that diagnosis was never absolutely confirmed and there is some debate about it amongst the oncologists - the lump grew to its size very quickly). She went into chemo immediately (FEC-D) and the lump responded quickly and by her last chemo neither the medical oncologist or surgeon could detect it in a physical examination.

She had a mastectory and axillary resection 3 weeks ago and we got the pathology results last Friday. We were disappointed by the fact there was still a 5cm lump and 5 positive nodes. She starts radiation in 2 weeks (chest, armpit,neck) and is taking tamoxifen. My question is .... what if that growth happened between chemo and surgery - would that indicate the need for more chemo? It crossed my mind briefly in the meeting with the surgeon on Friday but she was so upset I didn't want to go there until I had thought it through. Now she has pulled herself back up over the weekend so I really don't want to raise this with her if it's not an issue.

Any similar experiences here? My plan is to call the surgeon's nurse (fortunately I am a former patient and they know me well - I think we can get around the privacy issues by having a hypothetical conversation plus they know I have been with her at every appointment and treatment and ask many questions with her permission). I know this all leads back to the medical oncologist - just trying to sort it out in my mind. Thanks for any information.

Momine · November 2012

I had ILC, but also had a large tumor and 4X FEC prior to surgery. I had a good response, but not a complete response. There was still some live tumor and 7 affected nodes by surgery time. I then had 4 treatments with taxotere after the surgery as well as radiation.

Is the cancer hormone-receptive?

LizSei · November 2012

Thanks Momine - yes it is hence the Tamoxifen (she's premenopausal). She did the Taxotere on a neoadjuvant basis (the D in FEC-D). Was your taxotere always planned or did they add it when the residual disease was discovered?

Momine · November 2012

Sorry, missed the tamox. The taxotere was planned from the beginning for me. The only question was the timing of surgery relative to chemo. I did not realize the D was for taxotere.

How many chemo treatments did she have?

I think it is very sensible to ask the onc about all this, but I don't know the answer, I am afraid.

LizSei · November 2012

Thanks again - she had 3 FEC and 3 Taxotere (the D is Docetaxel which is the generic name I guess).

I called the nurse but today is a stat holiday in Canada which being self employed I forgot about!

rozem · November 2012

hi Liz

canadian here aswell. I asked the same question when I was going through neoadjuvant chemo, if there was cancer left would that mean more chemo? I was told no, once you have had a full course (which she did w FECD) then that was it. I believe if she was missing an anthracycline or the taxotere they may do that but she has already had both. I had a second opinion onc in the US who said the same thing. Both MO's said they would suggest entering a clinical trial after treatment but you would have to be at the large teaching hospitals for this, PMH or Sunnybrooke are involved in many clinical trials. Hope this helps

LizSei · November 2012

Thanks rozem - she is at PMH. I read a lot of reports today that concur with what you say - but I'm a bit of a dog with a bone because of the two physical exams that couldn't detect the lump, but then 4 weeks later there is a 5cm lump. I realize it's highly probable that they just couldn't feel it at the time but I don't want this to be overlooked as she heads into radiation. Did you do a further clinical trial?

rozem · November 2012

liz i have sent you a PM

TectonicShift · November 2012

Not all breast cancer is palpable. I had a 4 cm tumor right next to a 2 cm tumor -- so close that the pathologists don't know if it was two tumors or one big 6 cm tumor. It was not palpable at all. I had a breast exam (manual) one week before routine mammo and my doctor said, "Your breasts feel great." Then a week later - boom - IDC breast cancer, big tumors and pretty close to the skin too.

Also I had 11 positive nodes and none of them were palpable (in spite of the fact that one was well over a centimeter) and none showed up on ultrasound or MRI.

Kicks · November 2012

There is no guarantee that neo-adjuvant chemo will shrink the tumor(s) to where they are not there anymore. at least as it was explained to me - it is to try to shrink and to get clean margins (I'm IBC). I sounds like your friend's chemo did work as it did shrink the tumor.

You didn't say how long she waited between last chemo and surgery. For me, I had surgery 2 weeks after l ast A/C so that was the same time frame as between infusions. It had done it's job - it had gotten the IBC to form a lump (instead tof the nest/band) with clean margins and was smaller - did what was hoped for though still a fairly large area and 19 pos. nodes.

3 weeks after surgery I started 12 weekly Taxol, 25 rads a week after last Taxol. Different Drs. are different and treat differently as we are each different too. Chemo can be done before and after surgery - there can be 2 different chemo regimens done one after the other before surgery.

I am very glad that my Drs chose the TX plan they did (it made sense to Hubby, Son and me at the time.) Get it where surgeoon had a chance of getting it out, then hit again with the 'big guns' again to go after anything that might be lurking. Worked great for me - I'm still NED 3+ yrs (as far as I know) past DX (March will be 3 yrs post rads.). Been on Femara/letrozole since 2/2010.

LizSei · November 2012

Thanks all - Kicks congrats on almost 3 years out!

Her surgery was 5 weeks after the last treatment - she had FEC and Taxol before the surgery so she needed more recovery time.

I fully expect to hear that it was likely they just couldn't feel the lump (explaining why both the surgeon or MO declared it gone) and that no other chemo treatment is called for. I found a way to articulate it to her team - as follows:

"If you had known for certain that her lump was gone mid September (for example via an MRI) and then 5 weeks later after surgery there was a 5cm lump, would that change the current treatment plan - i.e. rads next?"

I spoke to her surgeon's nurse today and they're going to discuss it and review all the notes from the exams......all I care about is that everything is considered at the appropriate time. I am really grateful to have had such a caring, thoughtful response (of course we all spoke "hypothetically") rather than a dismissive you have no right here. They just want the best for her too.

Will report back...thanks for the comments.

Insun · February 2013

May I ask what happened after? I am in Toronto (PMH) and in same situation.

Tumor growth after neo adjuvant but before surgery - more chemo?

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