Breast case

[seper]

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I have a question/poll on use of elective nodal irradiation.
49 y/o with UIQ, 2.2 cm IDC, ER+/PR+/Her2+, 1/17 axillary node positive on dissection, no ECE.
received chemo

Would anyone treat whole breast only? Or should I start doing SCL or even IM for such cases?

 

[Gfunk6]

I would treat breast only + boost. No point in treating the axilla given the excellent dissection and low positive lymph node ratio. The chance of SCV/ICV nodal failure with Herceptin-based chemotherapy is < 5%. I don't believe in treating IMNs as the absolute benefit is miniscule.

 

[BobbyHeenan]

Though technically I think this patient would have been eligible for MA 20 and EORTC 22922, until that data is published I think it's fine to do whole breast here. If younger, triple negative, high grade, and LVSI, I'd probably add a SCLV field only (and I always contour nodal CTV per RTOG). For this case from the original poster I agree with Gfunk.

I personally would definitely not treat IM nodes, but back at my old institution depending on attending this patient may have had a SCLV (probably not an IM field though) added as well, loosely based on MA 20 and EORTC 22922.

 

[ramsesthenice]

Not going to be the norm, but our institution is very aggressive with nodes. Would not treat dissected Axilla but would include Scv and likely IMNs with tangents for almost all node + patients.

Our attendings cite the BC data showing OS benefit and separation of curves even in < 3 node cohort. The obvious issue is that was nodes and CW vs no rads at all.

MA 20 data will be helpful.

 

[RadRadRad]

Would treat SC (for reasons cited above if this was a macro met, would omit if micro met ). No axilla. Would not treat IMN, especially in left sided due to receipt of herceptin. Of note, the major Herceptin trials specifically did not allow IMN coverage, presumably because of concern for cardiotoxicity.

 

[thesauce]

Could go either way on this one. I would personally offer WBI and SCV per MA20 (no IMNs). Last year at ASTRO, nearly this exact case came up in the "difficult cases in breast CA" section and the panel largely opted for WBI only.

 

[medgator]

Tangents only. 1/17 with no ECE sounds low-risk enough to me, especially since she is getting chemo for triple+ disease

 

[seper]

Thank you all. I will treat WBRT +bst, no nodes, as was customary in my residency training. Can't argue much with anyone adding SCL though, agree.

 

[Neuronix]

I'd treat SCV and IMN chain in this case and I feel more strongly about it because this is a UIQ tumor. IMN is first echelon drainage for medial breast, and with axillary positivity the risk of positive, sub-clinical disease in the IMNs is high. MA-20 and EORTC trials are currently proving the survival benefit to this approach. Mean heart dose should be kept under 4 Gy which will likely require matched electron strip or other heart avoidance technique for left-sided tumor.

 

[seper]

Thanks for the input. You've brought up a point worth discussing. As far as I understand, IMN can be, but not very often are 1st echelon nodes for medial breast. In my pt, sentinel node (one that turned out to be positive) was in level 1 axilla.

I'd treat SCV and IMN chain in this case and I feel more strongly about it because this is a UIQ tumor. IMN is first echelon drainage for medial breast, and with axillary positivity the risk of positive, sub-clinical disease in the IMNs is high. MA-20 and EORTC trials are currently proving the survival benefit to this approach. Mean heart dose should be kept under 4 Gy which will likely require matched electron strip or other heart avoidance technique for left-sided tumor.

 

[Gfunk6]

Personally, I plan on ignoring the results of MA-20 until publication.