Failed Sentinel Node: ALND vs high tangents vs 3rd field?

[Burt Radnolds]

49 year old , lumpectomy, 1.6cm grade 2 IDC, neg margins, no LVSI, Er 98%/PR 1%/her2neu neg, oncotype 29. 2 failed SLN biopsies with no nodal tissue out by community surgeon. Med Onc already going to give AC>T. Surgeon adamant that she doesn't need ALND ("asked a guy at the academic center"), med onc doesn't care either way.

Would you:

1) Rock the boat and tell her she is getting non standard therapy and push hard for ALND?

2) Believe that radiation is as good as ALND and order an axillary U/S prior to chemo initiation with biopsies of suspicious nodes and then treat accordingly?

If she does not get an ALND and all signs point to node negative, would you do a)high tangents or b)add 3rd field?

Of note, current NCCN recommends ALND in this setting (failed SLNbx), but does say in an underlying bullet point: "For patients with clinically negative axillae who are undergoing mastectomy and for whom radiation therapy is planned, axillary radiation may replace axillary dissection level I/II for regional control of disease."

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[Palex80]

I'd say Option 2!
Go for it!

I probablly do the supraclavicular nodes too.

 

[medgator]

Yeah there are a few studies over the years (AMAROSE) that document it's probably OK in the clinically negative axilla.

 

[napoleondynamite]

Answers I'm sure would be all over the map - I don't think anyone knows for sure yet the value (or lack there of) of comprehensive nodal RT. If cNO, I personally would cover levels I&II but omit the SCV field. I don't think you need to push for an axillary dissection. Would you feel better somehow if she had one SLN that was positive and no ax dissection?