Breast cancer; prior lymphoma radiation

[BobbyHeenan]

I have a case of an otherwise health 50 ish year old with a T1 luminal A breast cancer. MRI breast staging confirms T1N0M0.

Prior radiation for Hodgkin's at age 15.

I know the boards answer here, but it's so tempting to consider this for APBI if she desires BCS. I think cosmestically, etc it'll be fine. I guess my biggest worry is just lifetime risk of further breast cancers.

So I'm leaning mastectomy(ies) here.

Thoughts?

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[Mandelin Rain]

Mild recommendation for mastectomies, though if she balks, I'd treat APBI without thinking twice.

She can always have mastectomies in the future if she develops another breast cancer.

 

[RADONC4285]

I have a case of an otherwise health 50 ish year old with a T1 luminal A breast cancer. MRI breast staging confirms T1N0M0.

Prior radiation for Hodgkin's at age 15.

I know the boards answer here, but it's so tempting to consider this for APBI if she desires BCS. I think cosmestically, etc it'll be fine. I guess my biggest worry is just lifetime risk of further breast cancers.

So I'm leaning mastectomy(ies) here.

Thoughts?

I would have 0 issues doing BCS and PBI. The way I would frame it to the patient is as such. Bcs/RT are likely very safe and the chances of curng THIS cancer are very high. However, due to lymphoma RT, your chances of ANOTHER breast cancer are relatively high. Do you want to just do mastectomy and have a much lower chance of an elsewhere breast ca to avoid the emotional toll of having to deal with another surgery? Or are you okay with BCT now to keep the breast and taking your fairly good chances?

 

[Ray D. Ayshun]

What's the risk of imn involvement?

 

[evilbooyaa]

What dose of RT? What fields? Presumably mantle, all the way to 45?

I think if you can do BCS and patient is interested in it go for it. I really wouldn't even balk at doing WBI.

 

[Ray D. Ayshun]

In all seriousness, id do rt if the patient wanted to after telling her I recommend a mastectomy.

 

[jondunn]

What dose of RT? What fields? Presumably mantle, all the way to 45?

I think if you can do BCS and patient is interested in it go for it. I really wouldn't even balk at doing WBI.

Agreed I have no major reservations about BCS here.

 

[RSAOaky]

What dose did she get previously and any radiation records?

This is a "discuss with the patient" situation.
She has 3 options:
1) Mastectomy - likely no radiation, has less to worry about w/ regards to second malignancy from her prior treatment
2) BCS + WBRT - higher risk of toxicity depending on what she got in the past, maybe there's some therapeutic benefit to "prophylactic" treatment of microscopic or pre-malignant lesions
3) BCS + APBI - lower risk of toxicity, good control, higher risk of out of field failure given the prior RT

With BCS she still has the option of salvage mastectomy, so if she's motivated to keep her breasts then I don't think it would be detrimental to her oncologic outcome. I would stress the importance of compliance with hormonal therapy and follow up MMGs. If she's an unreliable patient I'd lean more towards mastectomy.

edit: btw I need to fully acknowledge that the notion of "prophylactic" treatment of the breast with whole breast RT is not based on any fact and purely me pontificating. I'd be more inclined for option 3 but I wouldn't bite my thumb at someone doing 2.

 

[BobbyHeenan]

I have no clue about her prior dose. She was only 15, it over 30 years ago.

Thanks all for comments, in line with my prior thought process.

 

[Palex80]

I have a case of an otherwise health 50 ish year old with a T1 luminal A breast cancer. MRI breast staging confirms T1N0M0.

Prior radiation for Hodgkin's at age 15.

I know the boards answer here, but it's so tempting to consider this for APBI if she desires BCS. I think cosmestically, etc it'll be fine. I guess my biggest worry is just lifetime risk of further breast cancers.

So I'm leaning mastectomy(ies) here.

Thoughts?

I'd do APBI. She can always have a mastectomy later if she develops a second breast cancer.

 

[Ray D. Ayshun]

Identification of a Low-Risk Luminal A Breast Cancer Cohort That May Not Benefit From Breast Radiotherapy - PubMed

IHC subtyping was prognostic for IBR but was not predictive of benefit from RT. Further studies may validate the exploratory finding of a low-risk luminal A group who may be spared breast RT.

pubmed.ncbi.nlm.nih.gov

Yes, she's <60 but this is perhaps a special case. Women can always do a mastectomy later. She could do a mastectomy later if the surgeons take wide margins and you don't give any radiation.

 

[evilbooyaa]

Identification of a Low-Risk Luminal A Breast Cancer Cohort That May Not Benefit From Breast Radiotherapy - PubMed

IHC subtyping was prognostic for IBR but was not predictive of benefit from RT. Further studies may validate the exploratory finding of a low-risk luminal A group who may be spared breast RT.

pubmed.ncbi.nlm.nih.gov

Yes, she's <60 but this is perhaps a special case. Women can always do a mastectomy later. She could do a mastectomy later if the surgeons take wide margins and you don't give any radiation.

Or... she could do a mastectomy later after surgery + adj. RT in terms of not under-treating her extent of disease.

 

[Ray D. Ayshun]

Or... she could do a mastectomy later after surgery + adj. RT in terms of not under-treating her extent of disease.

I mean I know what we were taught and all, but if this is extremely favorable from a subtype pov with wide resection margins, is re rt really worth taking a 10 yr lr risk from 5% to 1%? It's not that straightforward in my mind.

 

[RickyScott]

I would also consider lumpectomy without xrt.

 

[TheWallnerus]

Prior RT aside… Aren’t we supposed to be doing a partial breast approach in ALL patients who are 50+ yo w/ T1N0 ER+?

 

[BobbyHeenan]

Thanks all for the input. She was offered mastectomy, lumpectomy, and lumpectomy with APBI. Of note, surprisingly her oncotype was kind of high at 26. No chemo though.

She has elected for APBI. I used slightly lower dose than Livi (I did 27.5 Gy/5, kind of mixing Livi and Fast forward dosing). She had a great set up, nice little seroma with clips, and is a great breath-holder. I was pleased with her plan.

She is compliant and will be on mammogram/MRI surveillance and an attempt at AI after treatment.

 

[TheWallnerus]

Thanks all for the input. She was offered mastectomy, lumpectomy, and lumpectomy with APBI. Of note, surprisingly her oncotype was kind of high at 26. No chemo though.

She has elected for APBI. I used slightly lower dose than Livi (I did 27.5 Gy/5, kind of mixing Livi and Fast forward dosing). She had a great set up, nice little seroma with clips, and is a great breath-holder. I was pleased with her plan.

She is compliant and will be on mammogram/MRI surveillance and an attempt at AI after treatment.

I do 26/5 for partial (mini-tangent approach, nothing too fancy). I learned this (the dosing) from the Royal College of Radiologists and @radmonckey.

 

[Ray D. Ayshun]

As we know, 27/5 will give like 60% worse toxicity than 40/15 while 26/5 is isotoxic.

 

[TheWallnerus]

As we know, 27/5 will give like 60% worse toxicity than 40/15 while 26/5 is isotoxic.

Here is absolutely the situation to use max point dose @RSAOaky; I recant somewhat

Max point dose: 26.01 Gy (body)

 

[RSAOaky]

Here is absolutely the situation to use max point dose @RSAOaky; I recant somewhat

Max point dose: 26.01 Gy (body)

Well now we can just agree to agree!

 

[Ray D. Ayshun]

Here is absolutely the situation to use max point dose @RSAOaky; I recant somewhat

Max point dose: 26.01 Gy (body)

That awfully conservative. I'm a bit more aggressive and allow max of 26.99 Gy.

 

[Palex80]

Of note, surprisingly her oncotype was kind of high at 26. No chemo though.

RT induced cancers tend to have bad biology. I am not sure if there‘s solid data for breast though.