Residual disease following neoadjuvant chemo

I should add.. metaplastic is notoriously chemo-resistant according to all of the studies.  I find that interesting in light of my post surgical pathology. 

Don't believe everything you read ladies.  We're all individuals.  My thought is to throw everything at TNBC upfront.  It's good to know you did everything in your power to stay healthy. 

While we still need much more research and progress needs to be made, I'm grateful we're at a stage where there's more trials for residual tumor.  I hope that continues at rapid pace!

Take care!


Edited by mindy555 - Apr 23 2012 at 1:08pm

Mindy and DebB,

Thanks for the info you posted.

Has anyone else received/found any other info on the RCB Index when deciding on additional
chemo after residual disease after neoadjuvant chemo/surgery?     Guess I am just surprised that
after the RCB Index paper was published that there does not seem to be much reference to it or
other articles on it.      

With caring and positive thoughts,
Grateful for today..................Judy

Hey Judy,

CJWatson,

Wish I had some answers.
Only have some thoughts and considerations for you.......and if you wish to discuss with your onc.

One way to get an answer and plan for your situation and questions is to consider/look into a 2nd opinion
and 3rd opinion if necessary with a TNBC expert.   
With TNBC, there are many gray areas. It seems that you have in your situation additional "gray" to the
gray areas.
The link for NCCN (National Comprehensive Cancer Network) Centers:
    https://www.nccn.org/members/network.asp       
The link for NCi (National Cancer Institute) Cancer Centers:
    For appointments at a NCI Center, ask for the TNBC oncologist.
    http://www.cancer.gov/researchandfunding/extramural/cancercenters      
    http://www.cancer.gov/researchandfunding/extramural/cancercenters/find-a-cancer-center

Another thought: have you had a radiation oncology consult (who has treated many TNBC) yet?
The radiation oncologist may or may not discuss considerations that would make the plan clear
      as to when radiation is best in your case.
The rad oncologist (with TNBC experience) may determine clearly and strongly that you are correct to
do the radiation first.
In which case, the rad onc can confirm his opinion about radiation first plan with your medical onc

In general...........and realize neither is exactly your case, CJWatson:
The usual order when the treatment plan includes surgery/chemo/radiation is:
             Neoadjuvant chemo (first) - surgery- radiation
                      or
             Surgery (first) - chemo -radiation.
The uniqueness of your situation is how to look at having had only the AC of a planned anthracyline/cytoxan/taxane protocol.    
This is the question for the oncologist, hopefully one with a lot of TNBC experience:
     Was the amount and doses of AC adequate to be "neoadjuvant chemo" or not?
          If not, what is best plan?

With HER2: equivocal, it would seem there would be consideration for an expert 2nd opinion
pathology expert consult re: your HER2 status. If one is HER2 positive, then there is need for
discussion with oncologist about a med for the HER2 such as Herceptin.

Both chemo and radiation are important.
       Chemo is for any stray cells IF cells broke off from the tumor into the lymph/blood system.
             Chemo is to decrease risk of distant recurrence.
       Radiation is for local control.
             Radiation is to decrease risk of local recurrence.    Recently, radiation has been found to
                         also some effect on the risk of distant recurrence (With chemo, of course, having
                         the greatest effect on distant site risk.)

When it comes to residual disease after neoadjuvant chemo-surgery-radiation. , the current standard
of care seems to be observation with the option of a clinical trial for residual disease. (Other members
please post and correct if needed what I just said.)   
There are some clinical studies for residual disease (such as the one Nita was in):
      http://www.clinicaltrials.gov/ct2/show/NCT01074970?term=cisplatin+PARP+Indiana&rank=1
      http://www.clinicaltrials.gov/ct2/show/NCT01401959?term=residual+disease++triple+negative+breast+cancer&rank=5
Note: CJWatson, I do not know if you would quality for clinical trial IF you were interested.
            There are certain criteria for the residual disease clinical trials.
            Some patients have too small residual disease to qualify for the some clinical trials.
            If one is interested in a residual disease clinical trial, discuss with one's oncologist.
Note #2:   The final determination of your HER2 status would need to be factored into any
                               future plan.

You may already be aware of the above.
With ALL the factors involved, it seems an expert, expert opinion would be helpful to sort all
      options out with all the pros and cons.

Whomever you have will have appointments/consults with, am sure you will have many questions.
You might like to consider including the following questions?
     1. Which NCCN or NCI pathology department will my specimen be sent to for a 2nd opinion/consut
              re: HER2 status?       (Importance of knowing your HER2 status.)
     2. Result of radiation oncologist (with TNBC experience) consult re: radiation plan.
             (Perspective for your treatment plan from a radiation oncologist.
     3. In your particular situation, what is the time frame within which next treatment should start?
     4. There are different chemo protocols for TNBC.   
                 Would the #doses and amount of AC you received be considered one of the protocol options?
     5. What is pros and cons of each additional chemo that might be a consideration ?
     
Please post any questions on what I have said.
Again, these are some thoughts for considerations....not advice.
You will gather the info as you are doing..........discuss/consult as needed with oncologists.....
       then you will make the best decision for you in your situation.


With caring and positive thoughts,
Grateful for today..............Judy

--------


Addendum:   The following is additional information on residual disease from above posts.

The MD Anderson calculator for RCB (residual cancer burden) can be used by any one.

Find at: http://www3.mdanderson.org/app/medcalc/index.cfm?pagename=jsconvert3

Article on RCB by W.F. Symmans and all:
    http://jco.ascopubs.org/content/25/28/4414.full

THE RCB calculator is used to determine risk of recurrence after breast cancer surgery that was
preceeded by neoadjuvant chemotherapy. In order to use the calculator, one needs to have a copy
of the surgical pathology report. (path after neoadjufvant)

Things to keep in mind (regarding Symmans article):
The RCB class can be:
       RCB:0       RCB:I       RCB:II    RCB: III
The RCB class is for the risk of distant recurrence in 5 years.
      (RCB:0 and RCB:I = low risk.    RCB:II = intermediate risk.    RCB: III = high risk)
Some path reports will have the RCB information on it.
Recognize the difference:
    Residual Cancer Burden:        This is the number that is calculated from the path info.
    Residual Cancer Burden Class:   The RCB "number" determines the RCB "class".
                                                             RCB:0       RCB:I       RCB:II    RCB: III
Example: the RCB could be 3    but the RCB class would be RCB II.
                 ( RCB Class II with an intermediate risk of distant recurrence in 5 years)
The article http://jco.ascopubs.org/content/25/28/4414.full noted above:
     Retrospective study.
     Included ER positive and negative and unknown (ER status).
     Included   HER2 positive and negative and unknown (HER2 status).
     Total patient population: 382 patients.
            241 patients who had T-FAC.      141 patients had FAC.
     Chemotherapy was not dose dense (not every 2 weeks).
     Cannot find any reference that radiation therapy was considered in the risk of distant recurrence    
             (If anyone does find radiation consideration, please post.)
If you had a pCR (pathologic complete response), this calculator would give:
            RCB:0    RCB Class: pCR.        Low risk for 5 year distant recurrence.

If anyone has any corrections or questions on the above, please post.

If you are looking at this information and articles for the first time, you may need to read it a few
times.

Edited by Grateful for today - Apr 28 2013 at 12:37pm

Judy, can I keep you as my guardian angel?

Hi I'm reading this and I'm confused. My path report says residual and my doctor told me pcr and my surgeon said pcr and put in her surgical notes. The I went to radiation and the doctor was going over all the pluses. He said pcr, Ned, neg nodes, brac negative, 12 yrs out etc.

I just signed into my patient portal and final report says. Complete path response and Ned .

Your asking what is says on my report?

Oh it's ok I'm willing to say what's on it. But the first line says residual recurrent high grade carcinoma measures up too 1.5cm

This is a top notch cancer hospital. Both surgeon and medical oncologist ended reports with those words. One lymph node says free of malignancy, no LVI ,clear margins,breast tissue contains evidence of previous biopsy, that's all it says.
Verbally she said she went down to pectorals then too ribs and all tissue removed negative

The oncologist surgeon sat down with me and my husband and wentvover path report after my surgery. She said cr and Ned. She said she wentbin as deep as she could and all that tissue was clean including node. Yet path report says what I mention above. After reading all your posting I'm like what the heck!!!!