Recent breast cases...

[Reaganite]

Some recent breast cases I saw. Interested in your take on treatment...

1. 65 year old female with a 2cm breast mass undergoes breast conserving therapy. Path shows invasive ductal cancer, MBR 6/9, ER/PR+, HER2-. Margins negative. 4/14 axillary nodes positive, no ECE. Would you treat the SCLAV?

2. 65 year old female presents with right breast tenderness and erythema. Physical exam/imaging studies significant for a a 3cm underlying breast mass, palpable 3 cm rt axillary "conglomerate", 2 cm rt suprclav mass, and a 1.2 cm right internal mammary node. Diagnosis of inflammatory breat CA made and patient started on neoadjuvant chemotherapy with carboplatin and taxol. Patient has good response with significant resolution of erythema and palpable abnormalities in the breast, axilla, and SCLAV. Imaging studies post chemo show only a residual 2cm mass in the axilla. Mastectomy is subsequently performed which is significant for a few scattered residual tumor cells, but margins are negative. Axillary dissection significant for 1/9 positive axillary nodes without ECE. What regions would you treat? In particular, would you treat the full axilla?

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[deleted4401]

1. If this patient was post-mastectomy, one would treat the SCV/ICV/axillary apex (based on consensus guidelines), as a significant component of the recurrences would be in that area (~20%, up to 40% in some series). So, it would follow that you would treat that region in this case, with the breast intact.

2. There isn't many cases that I would treat the axilla if adequately dissected. Arm edema is a beeeatch, and combining RT with dissection significantly increases risk of complications.

There is some data out there for certain factors (gross ECE, high percentage of positive nodes) for axillary recurrence, but those factors are more predictive for CW recurrence. If undissected and SLN positive, would run the patient through MSKCC nomogram (http://www.mskcc.org/mskcc/html/15938.cfm) to predict her chance of residual disease. If greater than 20%, go ahead and treat 'em. If between 10-20%, consider it, or just increase tangent border. If lower, forget it. If undissected and SLN negative, there is another nomogram from some JCO paper that I can't remember.

In this patient, I'm not sure if there is anything that would lead me to think she is at a very high risk of recurrence in the axilla alone. No gross ECE in nodes, ~10% positive nodes. Only 9 LNs removed, but it's after NAC, and there hasn't been a determination on what the cutoff is for an adequate dissection after chemo. I guess that would be the only thing that would concern me, but I'm not sure how to assess what her risk would be.

So, would treat CW, SCV/axillary apex, IMN (only because grossly involved at dx, otherwise never ever ever never). In a recent article from MSKCC, where they reported their inflammatory breast ca patients treated in the taxane era, they seemed to treat the axilla in a quarter of their patients, but it isn't explained when they chose to and when they didn't. 1 patient recurred in axilla out of 107 patients.

 

[Palex80]

1. Yes.
4/14 are one node too many involved.
When there are only 3 (or less) nodesinvolved, I tend to have a look at other risk factors like primary tumor seat (tumors sitting far cranial can go directly to the paraclavicular nodes), size of the involved nodes, number of nodes removed (3/10 is different than 3/18), node levels involved (apical involvement is a logical risk factor for paraclavicular failure), overall amount of axillary tissue removed.
Thus in some rare cases I offer paraclavicular irradiation in case of less than 4 axillary nodes involved. Post operative lymph edema is also always a factor, that has to be taken into account.


2. Chest wall, paraclavivular nodes, mammaria interna nodes.
One problem with respecting standard guidelines here, is that there were only 9 nodes removed. Our internal policy is to treat a surgically dissected, involved axilla, when the total number of nodes removed is under 10.
On the other hand, taking into account that I would also like to treat chest wall, paraclavicular nodes and mammaria interna nodes, I would get into a lot of "Lung&Heart-DVH-trouble" if I were to opt for axillary irradiation.
I would probably like to have a look at the initial imaging showing that axillary node (if there's any). There's a good chance that the node area and large parts of the initially involved axilla are in the tangents of the chest wall irradiation, so that I would opt for no axillary irradiation in this case.
I would also like to know how much the total volume of axillary tissue removed was and would probably call up the surgeon to make sure he cleared the axilla. Postoperative scars in the fatty tissue (&clips?) could also be helpful in order to judge how much axillary tissue the surgeon "got out".
Lymph edema is an important factor here as well. I would not offer axillary irradiation if the patient already had lymph edema.


And if all else fails to help you make up your mind:
Why don't you simply talk about it with the patient?
I think, that in cases where definitive evidence for the one or the other way is lacking, it's often a good idea to offer both treatments options to the patient and let them decide. You can't do this with all patients obviously, but usually you can tell once you start talking, which ones would like to decide for themselves.
Just present the facts, the options, the reasons for and against treatment and state that noone can really tell for 100% what's the right thing to do.

 

[Reaganite]

1. If this patient was post-mastectomy, one would treat the SCV/ICV/axillary apex (based on consensus guidelines), as a significant component of the recurrences would be in that area (~20%, up to 40% in some series). So, it would follow that you would treat that region in this case, with the breast intact.

I asked this question only because of a recent Red Journal article and some other retrospective data I've seen. This question came up with the attending treating the case, and he actually opted not to treat SCLAV.

Outcome after conservative surgery and breast irradiation in 5,717 patients with breast cancer: implications for supraclavicular nodal irradiation.
Livi L,

http://www.ncbi.nlm.nih.gov/pubmed/19540052?dopt=Abstract

 

[deleted4401]

Good point. Yeah, I saw that, and forgot all about it. It is true that N3 disease means distant badness. I guess I'd just feel odd leaving it out when you would treat the SCV if you were treating the CW after mastectomy.

 

[Palex80]

A similar point was also raised by the Overgaards:

http://www.ncbi.nlm.nih.gov/pubmed/18471914

The higher the systemic disease risk, the lower the survival benefit through adjuvant radiation therapy.
The lower the systemic disease risk, the higher the survival benefit through adjuvant radiation therapy.

The higher the systemic disease risk, the higher the local recurrence risk.
The lower the systemic disease risk, the lower the local recurrence risk.

I think these observations could change the way we think and act on adjuvant radiation therapy after mastectomy. We need to define our goals better and realise that some of the patients will benefit from radiation the most in terms of better overall survival, while others in terms of decrease in local recurrence risk.

 

[stlo]

...some of the patients that will benefit from radiation the most in terms of better overall survival, while others in terms of decrease in local recurrence risk.

I get what you're saying here, but how will this change what we do in practice? A local recurrence in the supraclav nodes can still be really painful for the patient. Are you arguing that for patients at highest risk of systemic failure (ie, those with lowest chance of overall survival benefit, right?) we should eliminate nodal beds and limit our fields to chest wall only?

 

[Palex80]

I get what you're saying here, but how will this change what we do in practice? A local recurrence in the supraclav nodes can still be really painful for the patient. Are you arguing that for patients at highest risk of systemic failure (ie, those with lowest chance of overall survival benefit, right?) we should eliminate nodal beds and limit our fields to chest wall only?

Sorry, I reformatted my text, so it makes more sense now.

What I meant to say is that we should maybe understand that we are treating post-mastectomy patients for different reasons and with different goals. Medical oncologists like to measure the indication of all their adjuvant treatments in terms of overall survival. If an adjuvant chemo does not proved a survival benefit, then they don't give it. We should not only look into the subject of overall survival but keep locoregional recurrence as well in mind.

I think this graph from the Overgaard publication is the most important one.

The "good" patients with low locoregional and systemic recurrence risk have only 11% locoregional recurrence risk without RT and 0% with RT. Yet at the same time this 11% additional locoregional recurrence risk translates into an 11% overall survival benefit through RT!
The "4:1-rule" (avoid 4 relapses in order to prevent 1 death) no longer applies here. Avoid one relapse in order to avoid one death is what this graph says!
If you were to use the "4:1-rule" in these patients, you would have barely gotten 3% (12:4) overall survival benefit and you would have people saying that 3% overall survival benefit aint enough to justify radiation!

The "bad" patients with high locoregional and systemic recurrence risk have 50% locoregional risk without RT and 14 with it.
Yet giving radiation does not help them at all in terms of overall survival, because the disease is already systemic.
The "4:1 rule" does not apply here either.

So:
We treat "good" patients to cure them from cancer, we treat "bad" patients to prevent a recurrence.


I would not limit the fields, if the patient has high systemic recurrence risk. A high systemic recurrence risk also means high locoregional recurrence risk. A paraclavicular nodal recurrence can still be quite unpleasant for a patient (even if she has bone mets at the same time).
The trial of Livi clearly demonstrated that paraclavicular failure rates rose sharply if patients with more than 3 nodes were not irradiated in the paraclavicular area.

 

[OTN]

1. I would treat the SCV, axillary regions. 4+ LNs: Include regional lymphatics. Might not add a PAB field if no ECE, since there was an adequate axillary dissection, etc. Would not bother with the internal mammary chain.

2. The fact the pt received neoadjuvant CTx cannot be ignored, and unfortunately I think it means we have to throw away a lot of the data we have on the issue. Given the pt had gross axillary disease in the axilla, SCV, and IM nodes, I would treat all three of those lymphatics in addition to the CW.

T

 

[deleted4401]

Was the 2nd case inflammatory or not? I thought it was and I didn't know there was a situation where you could omit RT, regardless of response to NAC.

Is there ever a situation when one doesn't tx?
S

 

[Palex80]

Is there ever a situation when one doesn't tx?

Brain mets.