Breast is the worst: another case!

[Palex80]

42 year old healthy female diagnosed with a huge DCIS , received mastectomy and sentinel lymph node dissection.

Inside the 11cm big DCIS, 2 invasive ductal carcinomas were found, biggest one was 2.2cm in diameter.
Axillary status is pN1 with a micrometastasis in 1 / 3 nodes (0.5 mm), no ECE.
Reconstruction was performed with an implant. Oncotype Dx score is 12, so no chemotherapy.

So, it's a pT2(m) pN1 (1/3mi) cM0 L0 V0 Pn0 R0 ER100% PR10% Her2- G2 invasive ductal carcinoma.

Looking forward to your votes and opinions!

---

Members don't see this ad.

 

[RadOncDoc21]

This is one of the worst of the worst! Since I’m simple, I’m just going to give old fashioned standard RT and comprehensive RNI (50/25). Large mass, lymph node positive, invasive, young age with reconstruction. I’m not into being “cute” with something tried and true when it comes to cancer.

I would also strongly consider the following two answer choices:

-whatever the breast surgeon wants me to do

-whatever the competition isn’t doing

 

[FrostyHammer]

I'd treat chest wall plus axilla I-III and SCV with Canadian or UK hypofractionation. Conventional fractionation for these cases I don't do anymore. Tolerated completely fine. Or treating per the Chinese randomized trial hypofractionation.

 

[TheWallnerus]

This is one of the worst of the worst! Since I’m simple, I’m just going to give old fashioned standard RT and comprehensive RNI (50/25). Large mass, lymph node positive, invasive, young age with reconstruction. I’m not into being “cute” with something tried and true when it comes to cancer.

I would also strongly consider the following two answer choices:

-whatever the breast surgeon wants me to do

-whatever the competition isn’t doing

I like your last two provisos.

But barring those I feel like RT would be a mistake. It’s a micromet. It’s a T1 lesion at most. 100% ER pos. Low oncotype. Plus you have an implant where chance for RT problems go way up vs normally. There is no hope for survival advantage here from RT. RT would have been crazy town here 20 years ago. Yes the elders ruined the specialty but maybe they knew some things. If there’s a single cancer cell seen in a single lymph node the knee doesn’t have to jerk the linac switch on every time.

 

[RadOncDoc21]

I like your last two provisos.

But barring those I feel like RT would be a mistake. It’s a micromet. It’s a T1 lesion at most. 100% ER pos. Low oncotype. Plus you have an implant where chance for RT problems go way up vs normally. There is no hope for survival advantage here from RT. RT would have been crazy town here 20 years ago. Yes the elders ruined the specialty but maybe they knew some things. If there’s a single cancer cell seen in a single lymph node the knee doesn’t have to jerk the linac switch on every time.

Oh trust me I’m fine either way which is why I hate breast. I can be swayed easily and sleep peacefully!

BTW, we’re at 3 responses with 3 different answers… shocker!

 

[Palex80]

BTW, we’re at 3 responses with 3 different answers… shocker!

I added the G2 to the characteristics and corrected the max. size of one of the tumors. It was 2.2 cm (Thank you Wallnerus for pointing out "It’s a T1 lesion at most" which got me thinking!), the initially typed 20mm were of course wrong, it's a small T2 with 22mm, indeed - sorry about that.

 

[thecarbonionangle]

I think you could argue for no radiation but you could probably split difference and do chest wall and low axilla alone with high-ish tangents all canadian hypofrac. I’d hypofrac all three field generally per China data.

 

[medgator]

I think you could argue for no radiation but you could probably split difference and do chest wall and low axilla alone with high-ish tangents all canadian hypofrac. I’d hypofrac all three field generally per China data.

Exactly how i feel, would do standard fx at that age to chestwall only which would include low axilla. Honestly could argue for no rt here also. Breast is the worst

 

[OTN]

Any LVI?

 

[TheWallnerus]

You guys would hypofx a chest wall implant? Is there data we can get away with that? I'd be afraid that'd be the PMRT implant case that would turn into a haint to come back to haunt. Especially in this admittedly gray zone case.

As of May (maybe earlier?) seems the NCCN begrudgingly allows for no RNI in low N-positive disease. Keep in mind IMPORT-LOW e.g. and many other trials (including, yes, START) didn't give N+ RNI and obv the favorable factor pts seem to do just fine with that. LOL at all the "category 1" discretionaries.

(I know this isn't a lumpectomy case. But because she gets a mastectomy it means she gets RNI, whereas lumpectomy pts don't need the RNI??)

 

[Palex80]

Any LVI?

Nope, L0.

 

[fiji128]

I wouldn't hypofx with an implant. Would do at least high tangents.

 

[TheWallnerus]

I wouldn't hypofx with an implant. Would do at least high tangents.

Yikes

Double yikes

 

[RadOncDoc21]

I’ve lost count in regards to the treatment recs for this patient. I hate breast (cancer)!

 

[RadOncDoc21]

I like your last two provisos.

But barring those I feel like RT would be a mistake. It’s a micromet. It’s a T1 lesion at most. 100% ER pos. Low oncotype. Plus you have an implant where chance for RT problems go way up vs normally. There is no hope for survival advantage here from RT. RT would have been crazy town here 20 years ago. Yes the elders ruined the specialty but maybe they knew some things. If there’s a single cancer cell seen in a single lymph node the knee doesn’t have to jerk the linac switch on every time.

Retrospective trial but did show there was an increase in LRR on multivariate analysis for the following:

size >2cm, age <50

Patterns and risk factors of locoregional recurrence in T1-T2 node negative breast cancer patients treated with mastectomy: implications for postmastectomy radiotherapy - PubMed

It has been suggested that patients with T1-T2N0 breast cancer who undergo mastectomy represent a favorable group for which PMRT renders little benefit. However, this study suggests that select patients with multiple risk factors including LVI, tumor size ≥2 cm, close or positive margin, age...

pubmed.ncbi.nlm.nih.gov

 

[Ray D. Ayshun]

I mean, is there a true right answer for what to do here if no invasive cancer was found? pTis(11 cm)N1(mi). I feel like PMRT still makes sense in that case.

 

[ramsesthenice]

I was not having a great morning so far. Then I read this thread and remembered that I don't treat breast. Now I feel much better. Thanks SDN friends

 

[TheWallnerus]

Retrospective trial but did show there was an increase in LRR on multivariate analysis for the following:

size >2cm, age <50

Patterns and risk factors of locoregional recurrence in T1-T2 node negative breast cancer patients treated with mastectomy: implications for postmastectomy radiotherapy - PubMed

It has been suggested that patients with T1-T2N0 breast cancer who undergo mastectomy represent a favorable group for which PMRT renders little benefit. However, this study suggests that select patients with multiple risk factors including LVI, tumor size ≥2 cm, close or positive margin, age...

pubmed.ncbi.nlm.nih.gov

I absolutely believe PMRT lowers LRR even in T1N0 ER+ breast cancer. However that and a dollar get you a cup of coffee. What if PMRT helps LRR but DECREASES survival? It might. (I'm being provocative.)

Regional lymph node irradiation in early stage breast cancer: An EBCTCG meta-analysis of 13,000 women in 14 trials

Conclusions: RT to regional lymph nodes in older (1961–78) studies increased the overall risk of death, probably explained by radiation exposure of the lungs and heart. Nodal RT in more recent (1989–2003) studies reduced breast cancer recurrence, breast cancer mortality and overall mortality without increasing non–breast cancer mortality. The proportional benefits from today's RT may be larger. Absolute benefits for individual women will depend on their absolute recurrence and breast cancer mortality risks.

 

[OTN]

Nope, L0.

Ah, I now see that you mentioned L0 in the original post. I hadn't seen that "L0" documentation for no LVSI before. I like it.

Given no LVI, I would not treat.

 

[Palex80]

Ah, I now see that you mentioned L0 in the original post. I hadn't seen that "L0" documentation for no LVSI before. I like it.

 

[fiji128]

I mean, is there a true right answer for what to do here if no invasive cancer was found? pTis(11 cm)N1(mi). I feel like PMRT still makes sense in that case.

I actually had this exact case a year ago that was also ER <1% and PR <1%. Path was reviewed with no evidence of invasive disease ever found. Sent for a second opinion with breast expert Dr. Friedman at UPenn. He did not recommend adjuvant RT.

 

[RadOncDoc21]

I absolutely believe PMRT lowers LRR even in T1N0 ER+ breast cancer. However that and a dollar get you a cup of coffee. What if PMRT helps LRR but DECREASES survival? It might. (I'm being provocative.)

Regional lymph node irradiation in early stage breast cancer: An EBCTCG meta-analysis of 13,000 women in 14 trials

Conclusions: RT to regional lymph nodes in older (1961–78) studies increased the overall risk of death, probably explained by radiation exposure of the lungs and heart. Nodal RT in more recent (1989–2003) studies reduced breast cancer recurrence, breast cancer mortality and overall mortality without increasing non–breast cancer mortality. The proportional benefits from today's RT may be larger. Absolute benefits for individual women will depend on their absolute recurrence and breast cancer mortality risks.

I only drink Starbucks so my cup of coffee is at least 7 dollars and my radiation is the best!

 

[TheWallnerus]

I actually had this exact case a year ago that was also ER <1% and PR <1%. Path was reviewed with no evidence of invasive disease ever found. Sent for a second opinion with breast expert Dr. Friedman at UPenn. He did not recommend adjuvant RT.

Yeah, from my reading, PMRT never makes sense in any DCIS case with negative margins irrespective the ER, or the Van Nuys Prognostic Index, or DCISion RT too I suppose.

 

[Ray D. Ayshun]

I actually had this exact case a year ago that was also ER <1% and PR <1%. Path was reviewed with no evidence of invasive disease ever found. Sent for a second opinion with breast expert Dr. Friedman at UPenn. He did not recommend adjuvant RT.

Good to know. I just had this case as well, though HR+. I also rec'd against PMRT, but as is the case with breast, wouldn't argue against someone who did.

 

[pikachu]

I mean, is there a true right answer for what to do here if no invasive cancer was found? pTis(11 cm)N1(mi). I feel like PMRT still makes sense in that case.

If there's an N+, wouldn't invasive disease by definition be present, even if not seen in the primary specimen? Disease couldn't get into the lymphatics without invading through the ductal basement membrane.

 

[evilbooyaa]

Let's add another answer to the picture.

I would encourage this young patient with a reconstruction to get a completion ALND
If 7+ additional LNs are taken, all negative (meaning 1mi/10 on final path), I'd be OK with no RT

Assuming no additional surgery:
Probably just do high tangents, but I could easily be convinced to do 3-field if discussed at tumor board. I am 100% not hypofrac'ing reconstructions off-protocol until RT-CHARM has resulted.

 

[TheWallnerus]

If there's an N+, wouldn't invasive disease by definition be present, even if not seen in the primary specimen? Disease couldn't get into the lymphatics without invading through the ductal basement membrane.

Node positivity in DCIS is (statistically) significantly greater than 0%. There was a push by some many years ago to make axillary analysis commonplace in DCIS, because up to 10% of (high risk) DCIS patients will have a measurable amount of disease in their nodes. But not upwards of 10% of DCIS patients appear to behave node positive obviously. Would be interesting to know if SLN was planned here (prob was because the DCIS was so big) in a seemingly pure DCIS case, or did they do it because on frozen intraop they found that she was really invasive disease with EIC.

 

[Ray D. Ayshun]

Yeah, from my reading, PMRT never makes sense in any DCIS case with negative margins irrespective the ER, or the Van Nuys Prognostic Index, or DCISion RT too I suppose.

Even node positive?

 

[RadOncDoc21]

Correct me if I’m wrong but I thought she did have invasive disease. Either way I’m sticking with my answer (comprehensive RT with RNI, standard fx) and collecting my check!

 

[Ray D. Ayshun]

Correct me if I’m wrong but I thought she did have invasive disease. Either way I’m sticking with my answer (comprehensive RT with RNI, standard fx) and collecting my check!

These conversations commonly diverge a little bit. Wondering about PMRT in node positive, large DCIS.

 

[evilbooyaa]

These conversations commonly diverge a little bit. Wondering about PMRT in node positive, large DCIS.

IMO no such thing as pTisN1Mi. Just unsampled pT1 (at least T1mi), especially if there's 11cm of DCIS.

 

[TheWallnerus]

IMO no such thing as pTisN1Mi. Just unsampled pT1 (at least T1mi), especially if there's 11cm of DCIS.

"In your opinion." Ha. How do you stage a DCIS with a node that's positive. What is the "textbook" answer. I don't think opinions count; I think you have to stage as TisN1. I could be wrong!

Even if the surgery itself caused the lymph node metastasis.

 

[TheWallnerus]

These conversations commonly diverge a little bit. Wondering about PMRT in node positive, large DCIS.

Divergences are good. Is there ANY data that PMRT affects outcomes in TisN1mi, much less TisN1? Do such patients even exist in the classically quoted PMRT data? There's probably a 100 patient 10 year retrospective analysis somewhere.

 

[Ray D. Ayshun]

Divergences are good. Is there ANY data that PMRT affects outcomes in TisN1mi, much less TisN1? Do such patients even exist in the classically quoted PMRT data? There's probably a 100 patient 10 year retrospective analysis somewhere.

In a separate thread I was wondering about a triple negative t3n0 ypt0n0, and nobody told me, yet, to observe after mastectomy. We're in a grey area for both, but I think the ops case or massive tisn1 would benefit more from pmrt. I can prove none of this.

 

[medgator]

In a separate thread I was wondering about a triple negative t3n0 ypt0n0, and nobody told me, yet, to observe after mastectomy. We're in a grey area for both, but I think the ops case or massive tisn1 would benefit more from pmrt. I can prove none of this.

Disagree... Tnbc is much worse biology, locally and systemically. We have rct's to prove this (Chinese t1/t2 pmrt trial)

 

[Ray D. Ayshun]

Disagree... Tnbc is much worse biology, locally and systemically. We have rct's to prove this (Chinese t1/t2 pmrt trial)

I don't disagree in general, but hasn't ypT0N0 addressed the biology issue in this particular case?

 

[medgator]

I don't disagree in general, but hasn't ypT0N0 addressed the biology issue?

One would hope.... Who knows how that will affect risk going forward though. We just don't have the data

 

[pikachu]

"In your opinion." Ha. How do you stage a DCIS with a node that's positive. What is the "textbook" answer. I don't think opinions count; I think you have to stage as TisN1. I could be wrong!

Even if the surgery itself caused the lymph node metastasis.

Tx maybe?

 

[TheWallnerus]

Tx maybe?

Maybe. But TBH I'm a little grateful more don't advocate for RNI (and PMRT) "irrespective" of a patient's nodal status. (Palex's patient was N1mi which behave more like N0 anyways.) @Palex80 hasn't answered us yet what he'll do. I predict it will be CW PMRT only (ignoring the node but pursuing LC in a small invasive primary with a very extensive intraductal component).

 

[Palex80]

Maybe. But TBH I'm a little grateful more don't advocate for RNI (and PMRT) "irrespective" of a patient's nodal status. (Palex's patient was N1mi which behave more like N0 anyways.) @Palex80 hasn't answered us yet what he'll do. I predict it will be CW PMRT only (ignoring the node but pursuing LC in a small invasive primary with a very extensive intraductal component).

Indeed, that's what I am planning to do.

 

[DCballa]

chest wall and low axilla (high tangents if no other risk factors). Ax LNs haven't been addressed yet so if they go ax dissection then probably done. If no ax dissection then 42.56/16 with no boost d/t implant