A 46 yr old presented with a 3x2 cm lump in the upper outer quadrant, with just palpable axillary lymph nodes. PET scan done suggests a hot lesion in the breast with non FDG avid nodes in axilla, but the mediastinum has two hot nodes (1cm ) with a SUV of 5. Is this stage IV?
Why don't you try and get a biopsy of the mediastinal node. You can still pretend that it is not stage IV i.e what is referred to as oligometastasis and treat with curative intent if mediastinal LN is positive.
Yes...that is our plan. We will try to biopsy it but if it turns out to be inconclusive, we are still going to treat her with a curative intent.
Indeed denying a curative intent would be a big decision at that stage. Where are the nodes and how hot is the primary ?
I agree that biopsy from mediastinal LN is needed. However, If the mediastinal LN are involved, I doubt that there is a benefit of treating her with curative intent. In most studies that investigated surgical resection of oligometastatic sites, mediastinal LN involvement was associated with significantly inferior prognosis, this applies to variety of carcinomas that metastasize to mediastinal LN.
Thank you for the information. Her nodes have persisted after chemotherapy.
There are few things to look for in this case.
1. Apart from primary breast lesion, are there any other metastatic lesion?
2. On PET-CT, we can fairly make out whether the non-FDG avid axillary nodes have preserved hilum or are they solid. If fatty hilum is preserved, we can be 90% sure that they are not metastatic.
3. Mediastinal nodes, whether ipsilateral or on contralateral side, as contralateral nodes have less chance of being malignant.
4. What is the condition of lungs, any sign of apical fibrosis suggesting old tuberculosis or any other sign of infection - GGO, pleural effusion, consolidation... which can explain the presence of nodes, as inflammatory nodes would also show FDG uptake as told by Dr. Atena and dual point imaging could have helped in this case. (I would assume that lungs are clear, otherwise reporting NM physician would have raised the doubt). In country like India, where tuberculosis is rampant, its common to find mediastinal nodes. Its always good to know the draining area of the lung segment having infection and finding nodes in that segment can be confidently attributed to infection.
5. Size of 1 cm is bit dicey as going by size criteria alone, anything below 1 cm is not significant (though I personally believe that 0.9 cm cannot be considered benign and 1.1 cm can be considered malignant) - we can re-look at the size.
6. Background of patient e.g. patient is living in highly congested region where chance of respiratory infection or level of air pollution is more, consider nodes to be inflammatory.
7. Post chemotherapy, nodes are persisting. Though what chemo was given is not written, i would assume second line chemo.. was given and no response.
With history provided, apart from primary breast lesion and mediastinal nodes, no other FDG avid lesion is present (presuming axillary nodes are also negative), it is highly unlikely that mediastinal nodes would be metastatic. Though we cannot be 100% sure without HPE, but we have to weigh the pros and cons and decide.
Good Luck....
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