Radiation therapy and Behcet disease

[Kroll2013]

Dear colleagues,
I will appreciate your advice concerning this patient.

61 years old patient, known to have a behcet disease that was well controlled.
she was diagnosed of a left Breast Invasive Ductal carcinoma, G1.
she underwent a partial mastectomy and left axillary nodes dissection.
Pathology: pT1N1M0, 3N+/42, free margins, Ki67:5%, ER+, PR + (40%) , Her2 negative , ECE negative

she received adjuvant chemotherapy, that was interrupted secondary to acute exacerbation of her behcet involving the left eye.

meds: colchicine, low dose steroid

She was referred for adjuvant radiation therapy that was refuted by her RO because of the increased risk of RI-brachial plexitis and dermatitis.

she is consulting for a second opinion.

What would you do?

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[RADONC4285]

Dear colleagues,
I will appreciate your advice concerning this patient.

61 years old patient, known to have a behcet disease that was well controlled.
she was diagnosed of a left Breast Invasive Ductal carcinoma, G1.
she underwent a partial mastectomy and left axillary nodes dissection.
Pathology: pT1N1M0, 3N+/42, free margins, Ki67:5%, ER+, PR + (40%) , Her2 negative , ECE negative

she received adjuvant chemotherapy, that was interrupted secondary to acute exacerbation of her behcet involving the left eye.

meds: colchicine, low dose steroid

She was referred for adjuvant radiation therapy that was refuted by her RO because of the increased risk of RI-brachial plexitis and dermatitis.

she is consulting for a second opinion.

What would you do?

I would consider Oncotype DX. We now have a phase III trial supporting its use for patients with 1-3 LNs. Granted it's about chemo use, but if it comes back very low, it would make you and the patient feel better about omission of RT. In either case however, I would tell the patient Behcet's aside, there is a locoregional control benefit and potentially a small survival benefit for RT. However, there is some sporadic retrospective evidence that Behcet's patients might have increased toxicity from RT, but it's not guaranteed. Then let her decide. the Oncotype might help push you/her one way or the other.

 

[evilbooyaa]

A quick search shows that there is mixed data on radiosensitivity in Behcet's patients:

One case series suggests no significant toxicity: Behçet's disease and breast cancer: A case series study Karatas F, Sahin S, Aytekin A, Erdem GU, Ates O, Ozisik Y, Aksoy S, Altundag K - J Can Res Ther

One case report suggested bad acute skin toxicity: DEFINE_ME

One paper suggests high rates of RT related morbidity but I can't see the paper to see what the toxicity was (skin vs brachial plexus): Malignancy in Behçet's disease: a report of 13 cases and a review of the literature - PubMed

In regards to your clinical scenario - the thought process of omitting radiation here is reasonable, in part because of '< 10% node positivity' comes to my mind here, given 3 out of 42 lymph nodes positive especially in a patient who has otherwise favorable risk disease.

I believe this is worth a discussion with the patient and see what her preferences are - if she is 'wants everything, is OK with a potential increased rate of toxicity', then treat RNI as you would. If she is scared of toxicity of combining RT with her Behcet's, not unreasonable given what I wrote above to omit RT.

I personally wouldn't get an Oncotype. It's probably going to be low, and all it's going to tell me is this patient got chemo for no reason, and wouldn't reassure me in anyway about her radiation.

*EDIT* - Missed the partial mastectomy bit - I would consider treatment of the lumpectomy cavity while simultaneously omitting RNI in this scenario.

 

[TheWallnerus]

In regards to your clinical scenario - the thought process of omitting radiation here is reasonable, in part because of '< 10% node positivity' comes to my mind here, given 3 out of 42 lymph nodes positive especially in a patient who has otherwise favorable risk disease.

 

[TheWallnerus]

She would do fine with partial breast RT; omitting the ENI will not affect her long-term survival, but omitting the breast RT might and certainly will affect long term LC.

 

[FrostyHammer]

She would do fine with partial breast RT; omitting the ENI will not affect her long-term survival, but omitting the breast RT might and certainly will affect long term LC.

Completely agree with this. PBI is definitely the way to go. 5 or 10 fractions.

 

[Palex80]

I'd treat. PBI sounds like a reasonable option in this particular case. I wouldn't do 5 fractions though and would rather stick to IMPORT-low fractionation.

 

[gmsquid]

Wait, I’m confused, with 3+ nodes she has a substantial risk of imn involvement. I know the primary survival benefit at least in retrospective series is in patients with 4+ nodes but there is a dmfs benefit at least in any node positive patient to rni based on two randomized trials in the modern era. Most of those patients only had 1 node positive too. Yes her node percentage is low, but her imn risk is at least 15% if not as high as 30%. Also with low grade er positive disease she is not likely to respond to systemic therapy anyways (bet you her oncotype is low). She’s likely to do well on hormonal therapy and if she fails, will fail distantly in 5-10 years. RT Given her young age I would favor rni here as it improves dmfs

 

[TheWallnerus]

Wait, I’m confused, with 3+ nodes she has a substantial risk of imn involvement. I know the primary survival benefit at least in retrospective series is in patients with 4+ nodes but there is a dmfs benefit at least in any node positive patient to rni based on two randomized trials in the modern era. Most of those patients only had 1 node positive too. Yes her node percentage is low, but her imn risk is at least 15% if not as high as 30%. Also with low grade er positive disease she is not likely to respond to systemic therapy anyways (bet you her oncotype is low). She’s likely to do well on hormonal therapy and if she fails, will fail distantly in 5-10 years. RT Given her young age I would favor rni here as it improves dmfs

Zoomed in very tightly one can not argue against you. (Except 61yo is young?)

But zoom out. Her risk of bone marrow involvement right now is equal or greater than her IMN risk. But no one will irradiate her marrow. So the appeal to irradiate IMNs on the basis of the likelihood of their positivity is always a shaky logic. And the risk of causing significant lymphedema with RNI is also prob greater than her IMN risk esp with 42(!!) nodes dissected. And this will be in a woman who another rad onc has turned down for RT. The behcet doesn’t worry me but if she had a pneumonitis, which RNI makes more likely, the rad onc will be blamed by that other rad onc all over town. And the patient will remember that another rad onc didn’t want to irradiate. We have to keep in mind when it comes to toxicities sometimes no good deed goes unpunished. This could be a case where a mid ground stance is nice.

Again back to your points. I now notice that for patients with 2 or less nodes positive the NCCN gives a category 1 recommendation to... ENI being discretionary in T1N1 (and that’s when the axilla is UNdissected). A category 1 to do ENI. And category 1 to not do it in the same situation. Breast, you’re crazy.