Case Study Anatomy of an Oncologist - Susan

The Importance of Axillary Node Involvement

The number of ipsilateral axillary nodes involved with breast cancer has become an increasingly important consideration in planning an attack on a patient’s primary disease. However, the use of the sentinel node technique1 for purposes of staging the extent of the primary breast disease is sometimes problematic. A clinical example will explain the dilemma that can be caused by a misreading of the axillary node situation. If N0 (absence of identified lymph nodes with cancer) is really N1 (cancer metastases found in one or more axillary lymph nodes), inappropriate therapy will be chosen.

1The sentinel note technique is one in which patients are injected in the area of the tumor with a saline solution of technetium-labeled colloid 2 16 h before surgery and with isosulfan blue dye at the time of surgery. Sentinel lymph nodes, identified by their presence of radioactivity and blue staining, are removed for microscopic evaluation of metastatic tumor.

Susan Cole, a widow at age 38, owned and operated a chain of pharmacies in the Chicago suburbs. There was no prior history of cancer in her family. She was healthy and fit and enjoyed an active social life. Her current love interest was a young surgeon who had been recently divorced. After a fun evening at the Art Institute of Chicago, he escorted her home. In the ensuing course of events, he palpated a mass in the upper outer quadrant of her left breast and was forced to assume the role of physician. She could tell he was concerned, and the evening ended after he explained what she must do immediately.

The following morning she called her gynecologist and asked his advice. He referred her to Dr. Gerald Powell, a general surgeon in practice at Northwestern Memorial Hospital and he ordered a mammogram.

She had a lesion in the described location and underwent an ultrasoundguided core biopsy. There was no doubt about the diagnosis, and she and Dr. Powell had a lengthy discussion as to how to proceed. He favored a standard mastectomy, principally to assure adequate staging. But Susan, being single and not wanting to lose her breast, convinced the surgeon to remove the lump and any nearby suspicious nodes followed by whole breast irradiation.

The surgery was uneventful. The cancer measured 2.3 cm in diameter. There was perilymphatic invasion in the area of the cancer. One of five left axillary (sentinel) lymph nodes was histologically positive for metastatic spread. The cancer was estrogen and progesterone receptor negative (ER2, PR2). At this point, Susan mentioned that, “by the way”, she would like a referral to Dr. Blumenschein in Arlington, TX.

Blumenschein did not like the tumor’s perilymphatic invasion and convinced Susan that Dr. Powell was correct. He felt that the limited nodal evaluation may have incorrectly downstaged Susan to stage II with less than three positive nodes with an expected 80% chance of cure. This would have permitted her to qualify for less therapy than she actually needed if she had been classified as stage II with more than three positive nodes. In that case, there would be concern that starting with radiation therapy would delay the time to chemotherapy by about 10 12 weeks and give any microscopic foci of metastases outside the radiation field time to grow and exceed a size that chemotherapy could eliminate,
i.e., ,1 million cells. Unfortunately, this level of sophistication was not common when therapeutic planning for Susan took place 23 years ago.

For some reasons, Susan decided to remain in Arlington for the mastectomy and lymph node evaluation that Blumenschein recommended. Dr. Bohn Allen was very accommodating, saw Susan immediately, and made arrangements for surgery to be done on the following day. The results were not what her referring physician had expected. Dr. Allen found 17 additional lymph nodes containing cancer. So Susan’s prognosis changed dramatically to less than a 20% chance of 5-year survival. The recommended treatment changed to induction with 6 courses of FAC (abbreviated as FAC36) to be followed by a combination of methotrexate, cisplatin, Cytoxan (trade name for cyclophosphamide), and 5FU with leucovorin for methotrexate rescue (MCCFUD)33. Chest wall and peripheral lymphatic irradiation was begun 4 weeks after MCCFUD.

For the 5 years following January 1988, Susan was seen by Blumenschein every 3 months. Visits to Texas then gradually diminished to every 4 months, then every 6 months. January 1995 could be considered a close call when symptoms of a headache led to the discovery of a dural mass. Fortunately, this proved to be a meningioma that was successfully resected 2 months later.

Today, Susan is continuing to enjoy life in Chicago and is sharing it with the surgeon who had been her date on that Art Institute evening. Blumenschein considers that Susan has been cured and that FAC was
the modality that successfully eradicated her microscopic metastatic disease. Although regional radiation therapy may have contributed somewhat to her cure, it is not clear in retrospect that MCCFUD was necessary.