Axillary lymph node

[deleted4401]

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78 year old man with left forearm lesion a year and a half ago. Excised, sq cell CA, grossly positive margins. +PNI. Recommended to see rad onc, never did. Came to me a little over a year later. 4 x 3cm mass. Oozing, red, painful. On exam, seem fixed to ulna. 55 Gy/20 fx. Boom - CR. Saw him for follow up this winter then in May. Still CR. 8 weeks ago, he felt something in axilla. Rapidly increased in size and became painful. CT - 4.2cm x 4.1cm node, a 3.6 x 2.6cm node and multiple other little guys. Bx - poorly differentiated carcinoma. Melanoma stains negative. Chest negative. Didn't fully assess head and neck, but very unlikely to met to axilla.

1. Palliative-ish - 30-40 Gy/10-15 fx
2. Definitive - 55/20 or 66/33
3. Axillary dissection + post op RT

Thinking 2, since primary was so responsive. But, 3 might be better LRC.

Or, other ideas?
S

 

[medgator]

unreasonable to get PET/CT for an N2A node that's come back in a year? If he has anything else going on, would probably take 3 off the table.

 

[deleted4401]

PET-CT not unreasonable. What about chemoRT? That's what medonc suggested. Kidneys not in great shape, so not cis.

 

[medgator]

PET-CT not unreasonable. What about chemoRT? That's what medonc suggested. Kidneys not in great shape, so not cis.

I would. Extrapolate from H&N. Again, just make sure it's a loco-regional recurrence.

Maybe he can get some erbi-TOX (heard that recently from one of my colleagues.... good descriptor of the generally minimized skin/mucositis issues with cetuximab). There is phase I/II data for it. The question is whether you can actually get the insurance company to pay up.

Probably equally weak data with carbo.

 

[CUBuffsgrad98]

Agree with PET. Would probably do dissection followed by RT, should give the best LC. Might be high risk for lymphedema, but a recurrence there could be a disaster. Chemo isnt unreasonable but not a ton of great data for it.

 

[Palex80]

66Gy to the axilla? Isn't that a bit too much for the plexus? I would be cautious. It's palliative.

 

[medgator]

66Gy to the axilla? Isn't that a bit too much for the plexus? I would be cautious. It's palliative.

Per the RTOG Lung protocol, plexus tolerance is 66 Gy. And let's not forget the historical H&N patients who were treated to the 70 Gy 😉 I generally keep 66 Gy as my tolerance as a max point dose.

 

[Palex80]

Per the RTOG Lung protocol, plexus tolerance is 66 Gy. And let's not forget the historical H&N patients who were treated to the 70 Gy 😉 I generally keep 66 Gy as my tolerance as a max point dose.

I don't think you can compare that so easily.
Point dose in a lung protocol and historical H&N data are not the same as treating the entire axilla to this dose, which is what is probably going to happen to SimulD's patient, bearing in mind that multiple nodes are affected.

Or would you treat the axilla to 66 Gy in a female breast cancer patient with ECE and close axillary margin? I wouldn't. I'd stop at around 54-59.4 Gy probably.

 

[medgator]

I don't think you can compare that so easily.
Point dose in a lung protocol and historical H&N data are not the same as treating the entire axilla to this dose, which is what is probably going to happen to SimulD's patient, bearing in mind that multiple nodes are affected.

Or would you treat the axilla to 66 Gy in a female breast cancer patient with ECE and close axillary margin? I wouldn't. I'd stop at around 54-59.4 Gy probably.

as would I, but in that case, the female pt has typically had an axillary clearance/nodal dissection. Fair point regarding the amount of axilla that would need to be treated. In that case, maybe just go to 63-64 Gy.

 

[deleted4401]

Hmm.
He had pCR with 55/20. The BED equivalent dose is 58 Gy/29 fx for a/b 10, and 62 Gy/31 fx for a/b 3. So, 60 Gy in 30 Fx sounds reasonable ... and safe for BP? Not a good candidate for surgery due to heart. Thanks
S

 

[medgator]

Hmm.
He had pCR with 55/20. The BED equivalent dose is 58 Gy/29 fx for a/b 10, and 62 Gy/31 fx for a/b 3. So, 60 Gy in 30 Fx sounds reasonable ... and safe for BP? Not a good candidate for surgery due to heart. Thanks
S

Flat 4 cm recurrence vs spherical 4.2 cm node with smaller nodes. Not sure if the same dose applies. Who knows. If you end up giving chemo, maybe 60 is enough. Just doesn't seem right for intact SCC. 60 is really a post-op dose if you look at NCCN guidelines for Tx of cutaneous SCC.