Chest Wall SCC

[Reaganite]

Interesting case I saw the other day... 50-something year old lady with an extensive post-pectoral squamous cell carcinoma. Lesion was actually discovered during removal of what was thought to be a ruptured silicone breast implant. Surgeon removed implant and capsule, but also noted multiple "clumps" of abnormal tissue throughout the post-pectoral region which turned out to be squamous cell cancer. PET is negative elsewhere. In the chest, there is basically diffuse PET uptake with no clear boundaries to the lesion(s). I've spoken to breast surgeon and thoracic surgeon, and while they want to do surgery (an extensive chest wall resection with flap reconstruction), they are almost certain they will get positive margins and have asked me to do neoadjuvant chemo-RT. Med Onc, however, is very much against the approach and wants surgery first. Thoughts?

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[napoleondynamite]

would have path reviewed..sounds odd..almost like a sarcoma

Regardless of the path, if surgery is on the table I would vote for preop RT since the margins will be questionable..aim at the target with a lower dose and perhaps a less morbid surgery. Strange to me that the medonc is not advocating for neoadjuvant therapy to assess biologic response.

 

[medgator]

would have path reviewed..sounds odd..almost like a sarcoma

Regardless of the path, if surgery is on the table I would vote for preop RT since the margins will be questionable..aim at the target with a lower dose and perhaps a less morbid surgery. Strange to me that the medonc is not advocating for neoadjuvant therapy to assess biologic response.

You will be screwed if they leave disease behind. I personally would stick with post op. No real data obviously one way or the other. Ditto for concurrent chemo, depending on the patient's insurance, the med onc may wonder if he/she will get paid

I wonder if irritation from the implant promoted it....

 

[napoleondynamite]

Do you think they are more screwed because of the preop RT or because of an R1/R2 after a wimpy dose (probably assuming 50Gy?)

If I offered preop RT, I wouldn't use a dose of 50Gy to the area of questionable margin..there's no data here, so you just have to use common sense and sit down with the surgeon and tailor a higher dose to the area of greatest concern. I personally would do something similar to what UAB published with their dose-painting approach with RPS..giving close to 60Gy to the areas of questionable margin and 50 Gy to the rest of the volume using SIB/IMRT. You will be treating a more certain target and smaller area..likely less lung & heart, etc. If they come back with positive margins after that, I'm not sure the patient is any more screwed than doing postop to a similar dose and less certain area. Assuming an a/b of 10 the BED of 2.3Gy x 25 fractions is right around 70Gy - you probably wouldn't go higher than that postop?

 

[medgator]

Do you think they are more screwed because of the preop RT or because of an R1/R2 after a wimpy dose (probably assuming 50Gy?)

If I offered preop RT, I wouldn't use a dose of 50Gy to the area of questionable margin..there's no data here, so you just have to use common sense and sit down with the surgeon and tailor a higher dose to the area of greatest concern. I personally would do something similar to what UAB published with their dose-painting approach with RPS..giving close to 60Gy to the areas of questionable margin and 50 Gy to the rest of the volume using SIB/IMRT. You will be treating a more certain target and smaller area..likely less lung & heart, etc. If they come back with positive margins after that, I'm not sure the patient is any more screwed than doing postop to a similar dose and less certain area. Assuming an a/b of 10 the BED of 2.3Gy x 25 fractions is right around 70Gy - you probably wouldn't go higher than that postop?

Yeah, but I feel like if the surgeon doesn't get it all out, you have the postop xrt option. What do you do with residual disease post op after giving 60 preop? We don't do preop for skin or head and neck scc, although we do so in esophageal. Not sure there is a real correct answer

 

[napoleondynamite]

If that were the situation after surgery and essentially 70Gy of XRT, my point is that I don't think the situation is worse than if you did surgery first and then tried to get 70Gy in to a larger volume..one could argue the radiobiology would favor preop if we're talking a similar dose. If you were left with an R1/R2 the options would have to be re-excision, surveillance or chemo..true no XRT at that point..but you haven't skimped on dose so I wouldn't feel I have done the patient a dis-service.

Agree there is no correct/standard answer.

 

[Palex80]

I have to say the idea of extensive preoperative radiotherapy with high cumulative doses around 60 Gy potentially with increased dose per day (>2Gy) as a neoadjuvant approach, when I know the surgeons are planning an extensive kind of reconstructive surgery, does not sound fun... Wound healing after such an intensive preoperative treatment is going to be tough and we know this basically from studies with lower doses in limb sarcomas comparing preop to postop RT.

I would stick to maximal safe surgery & reconstruction now, followed by adjuvant RT.
The way this case sounds it may very well be, that the tumor has already grown through the chest wall, thus the surgeons may intraoperatively discover pleural dissemination after.
In which case it's palliative anyway, so treating her with RT preoperative would have been an overkill anyway.