Breast Case

[Reaganite]

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73 year old female in otherwise good health s/p lumpectomy and SLNB with final path showing 0.7 cm invasive ductal cancer (ER+, BRS 5/9, LVSI-negative, margins widely negative) and 3/3 sentinel nodes with isolated tumor cells.

How would those ITCs impact your management? My well-respected med onc is pushing for observation.

 

[Gfunk6]

Need more information. Grade? LVI? What is the official N stage?

 

[medgator]

N0 but I+. Who knows what itc really mean. Some studies suggest a worse outcome, others don't. Honestly though, having had a case recently like this, I really had to think long and hard about how 3 nodes would get itc. Makes me nervous and pushes me towards treatment

 

[Pointless]

If this patient is otherwise in good health with a reasonable life expectancy, I would very much lean toward adjuvant RT. The i+ status makes the Hughes data not applicable to this patient, in my mind.

 

[Palex80]

I'd treat her breast. It' standard of care.

I wouldn't do high tangents though.

 

[medgator]

I'd treat her breast. It' standard of care.

There is randomized data in the U.S. that has lead to observation being an alternative standard of care in pts over 70 years of age with T1 ER+, node negative primaries as long as they get adjuvant anti estrogen therapy

http://www.ncbi.nlm.nih.gov/m/pubmed/23690420/

I think isolated tumor cells in three nodes makes this case concerning though

 

[Palex80]

I am familiar with the Hughes-trial, however you also have other trials like the Austrian-study or NSABP B21 pointing to a higher recurrence free benefit through RT.
The point that RT does not lead to increased overall survival is valid, but the same could also be said for tamoxifen in this very-low-risk patient population.
Yet no physician would probably defer from giving tamoxifen, right?

In the end, you need to weight the pros and cons for RT. We know that the RT of the breast leads to very low toxicity nowadays, perhaps even lower than tamoxifen in some cases (?).
RT is certainly more effective than tamoxifen, when it comes to local control as NSABP B21 demonstrated.
Furthermore hypofractionation is quite convenient for many patients, so that you can treat patients like her in 3 weeks with substantially reduced costs.
And certainly the whole partial breast options are out there (although we don't actually know, if we can do that in (i+)-patients), but if the patient had gotten an Intrabeam-treatment noone probably would be discussing tangents, right?

 

[Neuronix]

I would discuss this with the patient and see what she thinks. I'd offer treatment (agree with Palex) but wouldn't push hard about it. Hopefully the med onc would be ok with that approach.

 

[Reaganite]

Thanks for the replies. I recommended whole breast RT in tumor board largely for the reasons you guys mentioned...we're still fleshing out the significance of ITCs and whole breast is still the standard of care post-lumpectomy (and can be delivered with minimal toxicity with modern techniques).