lung and breast combo

[nancy555]

Hi,
I'm looking at a possible lung cancer (never smoked, though, or been around smokers; it was picked up when I had pneumonia last Nov & hasn't changed despite antibiotics). May 5th, the lung surgeon is planning to do a wedge resection, and if necessary, a lobectomy. I'm dreading this, especially since what's showing up is located in the upper posterior part of my lung, so at the least, 2 of the keyholes will be in my back/back of shoulder, right where I have my worst problems with my severe fibromyalgia. I've also just been diagnosed with breast cancer in the opposite breast: I just got my wire-guided excisional biopsy results yesterday. the tumour is located way back near the chest wall: invasive adenocarcinoma tubular, 1.1cm, grade 1, excision margins clear, estrogen pos+++, greater than 90% of invasive cells; progesterone. pos+++, approx. 10% of invasive tumor cells; HER/2 neg. Ductal and lobular carcinomas are in situ. The breast surgeon plans to do a sentinel node biopsy at the same time on May 5th.
My questions are: (since I'm dreading the lung procedure because of my fibromyalgia), 1) would it make sense to check out the lymph nodes first, even if it means two anesthetics, if it might make the lung procedure pointless? 2)) Since my breast tumour was so close to my chest wall, and my mother's breast cancer metastized to the bone, would a bone scan be a good idea at this point, to help determine txt? 3) If my lymph nodes are malignant, might that change txt for lung & breast, and might it perhaps make the lung procedure pointless (I'm dreading the lung operation because of my fibromyalgia & am trying to avoid it!!.) I'm only 54, but I'm more interested in quality of life than length of life, when I'm dealing with basic needs
Thanks so much.  All this is so overwhelming, not just that I'm dealing with both breast and lung, but especially the effect it will all have on my fibromyalgia, and how it will make my disabilities even worse (driving, personal care, etc)

[Fernando Roque, MD]

Hi.  Biopsy of the lung mass can either be done via the bronchoscope (particularly if the mass is inside the airways), via a needle inserted through the chest wall (CT scan guided needle biopsy), or by video assisted thoracic surgery or VATS.  VATS involves making a small incision on the chest wall and sticking a flexible fiberoptic scope to directly visualize the lungs.  Typically, the scope also has instruments bundled with it to do biopsy or surgery.  

Is your thoracic surgeon aware of the breast biopsy results? Since the breast biopsy came back as positive for cancer, there is a real possibility that the lung mass is a metastatic lesion (it is less likely for primary lung cancer to metastasize to the breast than vice versa).  I think your doctors should verify the histology of that lung mass first, USING A LESS INVASIVE PROCEDURE such as a CT guided needle biopsy, rather than immediately proceeding with a wedge resection.  A wedge resection or a lobectomy can cause a significant decrease in lung function, and I would only recommend this procedure if I were sure that the lung mass is primary lung cancer, since resection is potentially curative if this is the case.

Anyway, this is just my opinion based on the facts you've posted.  Your doctor has a better overall view of the case, and he may have some very good reasons (which I don't know about) for deciding on a wedge resection.

[nancyspenc]

Thanks so much for your detailed answer.
Re: my lung: I had a bronchoscopy done, but it came back inconclusive. They were no further ahead after than before the procedure, except for being able to pinpoint the bacteria (pneumonia) I was fighting. The respirologist did ask the surgeon to postpone the surgery by 2 months (from March  to May 5), to give me another couple months of anti-biotics, but there was no change. I see him this Friday 2nd, before my Monday surgery (the surgeon already decided she wanted to go ahead). The surgeon says, since we don't know for sure what it is, it hasn't changed and it shouldn't be there, it's got to come out. I asked if a PET scan could differentiate between infection, benign & malignant, but she said infection would light up too, so it's pointless.I've so badly wanted to avoid this surgical procedure, especially since it may not even be necessary IF it's from my breast cancer .
Two problems I face: 1) it would mean asking to postpone/cancel the lung surgery a second time (actually the respirologist postponed it the 1st time); and 2) I can just picture the lung surgeon saying, I'm sorry it's metastic breast cancer (if it is), but we still don't know for sure what's in your lung, so it still has to come out (so frustrating! I had really hoped that, with the fancy machines these days, they'd be able to tell, non-surgically, if the thing is malignant, benign or infection!)                                               1)When you asked at the beginning if the surgeon had done a separate lung biopsy, were you referring to bronchoscopy and/or a VATS?  As mentioned above, I've had a bronchoscopy, and I think she's going to do a VATS, since she mentioned a little camera, but she also said wedge resection. She'll take out a "slice of pie" and biopsy it while I'm still under. If it's malignant, she'll do a lobectomy; if it's benign, she'll close me up with just the wedge resection.
2) When  a VATS is done, is it commonly done without the wedge resection? Does it use one key hole on the side, or 3 (one on the side, 2 on the back, in my case)?
Thanks again, even for reading all this!  I really appreciated your reply.

[Fernando Roque, MD]

Hi.  Did your doctors do a separate biopsy of your lung mass? If they did, what were the results?  I'm asking because if the histology of the breast and lung biopsies are similar, this may be a case of metastatic disease in either the breast or the lungs, instead of double primary sites (which is a less common occurrence).  I'm thinking that maybe the lung lesion signifies metastatic spread from a primary breast cancer (of course, this is just my theory based on what you posted).  If this is the case, then a wedge resection/ lobectomy is unnecessary, since the metastatic lung lesion would respond to chemotherapy given for the breast cancer.  

As for your questions, I'm going to try answering them per item:

1. The sentinel lymph node biopsy should be done together with surgery of the breast mass, either a mastectomy or lumpectomy.  If my theory is correct and the lung mass is actually a metastatic lesion, then the lung surgery would indeed be pointless.

2.  A bone scan is not needed if you do not have any symptoms hinting at bone metastases (e.g. bone pain, elevated serum alkaline phosphatase).

3.  If the sentinel biopsy find those nodes malignant, it is likely that the cancer cells  in the nodes originated from the breast (regional metastases).  This would mean that in addition to breast surgery and chemotherapy, you will also need additional radiation treatment which would include the area where the nodes were harvested (the armpit).  However, the presence of sentinel node metastases will not change the need for resection of the lung mass, ASSUMING that the lung mass is a separate primary.  If that lung mass signifies distant metastases coming from the breast, lung resection is unnecessary, as I have stated earlier.  This is why it is important to know if the breast and lung masses have similar histology, since it has a lot of impact on how your case is going to be treated.