Post Mast XRT for isolated cells in 1 LN in setting of ALNBx only?

[Mandelin Rain]

T1N0(i+) Multifocal Lobular
Grade 2
2mm margins
No LVSI
ER+ PR+ HER2-
1/3 LN with isolated tumor cells
50 years old
No chemo

Axillary Dissection (probably textbook answer, but always tricky in practice)? Post Mast XRT? No further treatment?

---

Members don't see this ad.

 

[seper]

I would not radiate. Population based studies point to ITC not affecting outcome. I would also disagree about ITC needing axillary treatment being a "textbook answer".

 

[BobbyHeenan]

Tough case. Is there a role for an oncotype here to help guide chemo? I suspect it would be low, but if high may help guide systemic options.

I would say if low oncotype just AI alone, no XRT and no axillary dissection.

Aside: Why the mastectomy for T1 disease?

 

[Gfunk6]

Agree with BobbyHeenan

 

[Neuronix]

Just for discussion, would anyone treat if this was the same scenario but the node had a micrometastasis 0.5 mm in size, N1(mi)?

 

[Mandelin Rain]

Thanks.

Had a Mammaprint = Low Risk so no chemo.

Mast for multifocal, multicentric disease. Expander placed (another complicating factor)

She's 6 weeks out from surgery, so going back in is not an attractive option.

I'm not sure there is a textbook/board answer in this case. I would think that in the mastectomy setting, any doubt on a SLNBx would prompt a dissection at an academic center, but I could be very wrong. I'm not aware of data to support any approach (but that definitely doesn't mean it doesn't exist).

 

[Mandelin Rain]

This seems relevant:

Breast Cancer Res Treat. 2015 Oct;153(3):599-606. doi: 10.1007/s10549-015-3560-7. Epub 2015 Sep 4.
Prognostic significance of axillary dissection in breast cancer patients with micrometastases or isolated tumorcells in sentinel nodes: a nationwide study.
Tvedskov TF1, Jensen MB2, Ejlertsen B3, Christiansen P4, Balslev E5, Kroman N6.
Author information

Abstract
We estimated the impact of axillary lymph node dissection (ALND) on the risk of axillary recurrence (AR) and overall survival (OS) in breast cancer patients with micrometastases or isolated tumor cells (ITC) in sentinel nodes. We used the Danish Breast Cancer Cooperative Group (DBCG) database to identify patients with micrometastases or ITC in sentinel nodes following surgery for primary breast cancer between 2002 and 2008. A Cox proportional hazard regression model was developed to assess the hazard ratios (HR) for AR and OS between patients with and without ALND. We identified 2074 patients, of which 240 did not undergo further axillary surgery. The 5-year cumulated incidence for AR was 1.58 %. No significant difference in AR was seen between patients with and without ALND. The age adjusted HR for AR if ALND was omitted was 1.79 (95 % CI 0.41-7.80, P = 0.44) in patients with micrometastases and 2.21 (95 % CI 0.54-8.95, P = 0.27), in patients with ITC after a median follow-up of 6 years and 3 months. There was no significant difference in overall survival between patients with and without ALND, when adjusting for age, co-morbidity, tumorsize, histology type, malignancy grade, lymphovascular invasion, hormone receptor status, adjuvant systemic treatment and radiotherapy, with a HR for death if ALND was omitted of 1.21 (95 % CI 0.86-1.69, P = 0.27) in patients with micrometastases and 0.96 (95 % CI 0.57-1.62, P = 0.89) in patients with ITC after a medium follow-up on 8 and 5 years. In this nationwide study, we found a low risk of AR on 1.58 % and we did not find a significantly increased risk of AR if ALND was omitted in patients with micrometastases or ITC in sentinel nodes. Furthermore, no significant difference in overall survival was seen between patients with and without ALND when adjusting for adjuvant treatment.

KEYWORDS:
ALND; Breast cancer; Isolated tumor cells; Micrometastases; Sentinel node

PMID: 26341752

Not sure what proportion received XRT vs. not, but I'm going with no further treatment. Thanks for the input.

 

[OTN]

It's for this reason exactly I wish they would stop looking for ITCs. No clear data that knowing about them does anything for anyone.

 

[medgator]

It's for this reason exactly I wish they would stop looking for ITCs. No clear data that knowing about them does anything for anyone.

yup like i+ Never order a test when you don't know what to do with the results

 

[Phantom1]

Yeah in these borderline cases there may be no absolute "right or wrong" answer regarding post-mastectomy XRT. We know post-mastectomy XRT decreases risk of loco-regional recurrence by around 60-70%. So if her absolute risk of loco-regional recurrence is say 10% then it would decrease to 3%. Would she benefit from this risk reduction? I feel in these cases the patient's personal preferences can also play an important role.. also is it left sided or right sided? Is there a decreased risk of cardiac toxicity if right sided?

People talk about the data deferring radiation if hormone therapy can be used. But that data is for older women who committed to years of hormone therapy, which is no walk in the park. There are acute and long term side effects with hormone therapy which one could argue are worse for QOL than 4-6 weeks of XRT... Interesting case to debate..