Chemo/RT sequencing, positive margin breast CA

[Reaganite]

I have a 79 year old lady (good kps) s/p MRM and axillary node "dissection" with final pathology showing:

Multifocal IDC with largest mass measuring over 7cm. No skin involvement. +LVSI. ER/PR/HER2 not mentioned in report. Deep margins focally positive. 1/3 axillary lymph nodes positive (extensively replaced 4cm node with ECE).

How do you guys feel about sequencing of RT and chemo in this case?

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[napoleondynamite]

With both the positive margin and ECE with inadequate nodal dissection, she's at high risk for locoregional recurrence so I would push for rads first in this instance.

 

[RadRadRad]

If pec fascia was taken and tumor was not invading into pec muscle I think you could consider the deep margin negative.

 

[Burt Radnolds]

I agree with RadRadRad. However, if only 3 nodes were taken in what was deemed a true axillary lymph node dissection and not a sentinel node biopsy, I would begin to question the overall quality of the surgery performed.

 

[medgator]

I agree with RadRadRad. However, if only 3 nodes were taken in what was deemed a true axillary lymph node dissection and not a sentinel node biopsy, I would begin to question the overall quality of the surgery performed.

Or the quality of the reading pathologist.

Nothing can be done about either post surgery other than xrt. In terms of the original question, the sequencing data for chemo vs xrt isn't particularly strong and if there is a really strong concern from the surgeon about the margin and extent of ece, imo it's not unreasonable to start with xrt first. Both are important treatments with defined impacts on OS.

 

[napoleondynamite]

There is some joint center data out there somewhere, which I tried to dig up in my files but couldn't find it..but we used to quote it in residency - I think in the situation of a positive margin the recurrence rate was something like 30% if you started with chemo vs single digits if you started with XRT...which was why we always went with RT first. I'll try to dig that up and post the link if I can find it.

 

[Irradi8or]

There is some joint center data out there somewhere, which I tried to dig up in my files but couldn't find it..but we used to quote it in residency - I think in the situation of a positive margin the recurrence rate was something like 30% if you started with chemo vs single digits if you started with XRT...which was why we always went with RT first. I'll try to dig that up and post the link if I can find it.

This is the 2005 update I think by Bellon et al...

http://jco.ascopubs.org/content/23/9/1934.long
http://www.ncbi.nlm.nih.gov/pubmed/15774786?dopt=Abstract

End of results:

"For the 123 patients with negative margins, the crude local recurrence rates for CT-first and RT-first patients were 6% and 13%, respectively. Corresponding rates of distant and regional recurrences were 18% and 26%. Among women with close margins (n = 47), crude local recurrence rates were 32% and 4%, respectively; distant/regional recurrences were 37% and 43%. In the group with positive margins (n = 51), local recurrences occurred in 23% of CT-first and 20% of RT-first patients; corresponding distant/regional recurrences occurred in 29% of CT-first patients and 35% of RT-first patients."