Breast Case

Reaganite

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    41 y/o female, 6cm IDC, 2 enlarged axillary lymph nodes on preop imaging (2cm and 1.5cm respectively), IDC, ER 10%, PR/HER-2-negative. 2cm axillary node core biopsy negative (clip placed at time of biopsy). BRCA-negative. Received neoadjuvant ACT with imaging showing complete resolution of breast mass and "normalization" of both enlarged nodes. (Per imaging, the 1.5 cm node initially showed thickened cortex but now normalized with fatty hilum). Got simple mastectomy + SLNB + immediate implant reconstruction. 0/1 nodes + (previously clipped node). Path CR. Surgeon supposedly presented at her "local tumor board" where rec was for No RT.

    Would you radiate?
     
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    KHE88

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      Are you asking if we would radiate nodes?

      It sounds like we are talking about a 41 year old with essentially a large triple negative clinically node positive breast cancer who had NAC followed by lumpectomy and SLN Bx.

      I think omitting whole breast radiation would be wrong, and I would not omit nodes off trial.

      The breast world confuses me at their constant desire to, dangerously sometimes IMO, de-escalate. I go balls to the wall with something like this. Conventionally fractionated whole breast, boost, RNI including IMC, DIBH regardless of side. Probably discuss with med onc to see if they want to throw some pembro at her too. Call me crazy!
       
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      Reaganite

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        I would definitely (as downside is very limited) and include the axilla, or use high tangents but this is currently the subject of a trial?

        Oops, forgot to add some important nuances to this case including they already reconstructed her and supposedly presented in local tumor board where rec for no RT made. Wanted to make sure I wasn't missing some new line of thinking that doesn't make this a slam dunk XRT case.
         

        KHE88

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          Oops, forgot to add some important nuances to this case including they already reconstructed her and supposedly presented in local tumor board where rec for no RT made. Wanted to make sure I wasn't missing some new line of thinking that doesn't make this a slam dunk XRT case.

          I knew I was missing something. The reconstruction makes sense now. My brain saw simple mastectomy and substituted partial mastectomy. Regardless, I would still radiate. Multiple high risk factors. I don't know any cases where I would offer chestwall without RNI.

          How long ago was her surgery and what kind of reconstruction did she have?
           

          scarbrtj

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            We have discussed very similar scenarios to this in the past. The two things I would "pick on" would be she is technically cN0 and pN0, cT3. Not a huge benefit to PMRT in those T3N0 groups to start with. Second and most important thing that we overlook in the rad onc sphere is the profound prognostic ability that CRs to chemo give in breast cancer. A CR to chemo gives a huge benefit in survival; so big, that PMRT's potential OS improvement here in this case might be like the increase in total wind speed during a hurricane from a mouse fart. Except this is also a mouse fart in a 41yo; what harm can a mouse fart have, right? I can probably cite you some data that PMRT in ~40yo's with CRs to chemo and who are pN0 and cN0 have a long term survival detriment from PMRT. Anyway, I would not treat. The "node story" here, while a little dramatic, is not a decider.

            It sounds like we are talking about a 41 year old with essentially a large triple negative clinically node positive breast cancer who had NAC followed by lumpectomy and SLN Bx.
            Either I misread or you did heh. I read ER+, node negative, mastectomy.
             
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            evilbooyaa

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              While radiographically suspicious LNs are suspicious, if they are biopsy negative, we treat them as negative, unless they have like PET positivity or some other unique situations.

              cT3N0 ER+, PR/Her2-. The fact she had a pCR to AC-T is a very good prognostic factor.

              I would not radiate her given she had a mastectomy.

              I do think cT3N0 is a unique scenario but with a pCR to chemo I'd be inclined to leave her be.


              Was there evidence of treatment effect in the removed LNs on final sectioning? This would likely push me to treat and say that the initial biopsy was just a false negative.
               

              KHE88

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                We have discussed very similar scenarios to this in the past. The two things I would "pick on" would be she is technically cN0 and pN0, cT3. Not a huge benefit to PMRT in those T3N0 groups to start with. Second and most important thing that we overlook in the rad onc sphere is the profound prognostic ability that CRs to chemo give in breast cancer. A CR to chemo gives a huge benefit in survival; so big, that PMRT's potential OS improvement here in this case might be like the increase in total wind speed during a hurricane from a mouse fart. Except this is also a mouse fart in a 41yo; what harm can a mouse fart have, right? I can probably cite you some data that PMRT in ~40yo's with CRs to chemo and who are pN0 and cN0 have a long term survival detriment from PMRT. Anyway, I would not treat. The "node story" here, while a little dramatic, is not a decider.


                Either I misread or you did heh. I read ER+, node negative, mastectomy.

                Do you believe that she was clinically node negative? How strongly do you believe that? I am not very inclined to believe that biopsy result.

                And, yes, I would be more inclined to think of this as a triple negative breast cancer with an ER of 10% and a pCR to NAC: Low ER+ Breast Cancer: Is This a Distinct Group?

                So I'm approaching this as much more of a clinically node positive triple negative cancer in a 41 yo.

                Even if you say, well she's a T3N0, the data for omitting PMRT is T3N0 cases frankly isn't great. The Nagar study shows a good benefit to PMRT in these patients, although it's true nobody with a pCR recurred on that study. I will look at other risk factors rather than just say all cT3N0 can avoid PMRT. In this case, she has multiple other risk factors that I really think, when added together, make PMRT a no-brainer in this situation. At the very least, I think this warrants a discussion with the patient and she should be offered treatment if she wants it even if you don't think it's really necessary.

                I'm assuming this was a grade 3. Was there LVSI? Margins?
                 

                scarbrtj

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                  Do you believe that she was clinically node negative? How strongly do you believe that? I am not very inclined to believe that biopsy result.

                  And, yes, I would be more inclined to think of this as a triple negative breast cancer with an ER of 10% and a pCR to NAC: Low ER+ Breast Cancer: Is This a Distinct Group?

                  So I'm approaching this as much more of a clinically node positive triple negative cancer in a 41 yo.
                  I think the only problem is, your approach (and belief) has zero data to make it seem reasonable! We can debate ER positivity thresholds, but why. It was 10% in this case. We'd be debating all day. And frankly you and I ain't smart enough to debate it. I have followed about two patients on long-term anti-estrogen therapy... which I've prescribed... in my career. And never in Stage IV cases, etc etc.
                  But fine, have it your way because I like you. She's triple neg. Because of having a CR in the tumor and nodes (even if they were truly positive), this "TNBC" patient (she's not!) has a 3y (locoregional) ~95% event free survival probability that beaming her chest wall and inchoate nodal regions won't appreciably nudge.

                  And I say again there is a trend toward survival detriment here.
                   
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                  scarbrtj

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                    I'm assuming this was a grade 3. Was there LVSI? Margins?
                    cT3N0 disease s/p mastectomy. I would not irradiate, unless LVSI noted.
                    Also the LVSI thing is a bit overwrought IMHO. Sure there's some data that it may play a role, of course. But again, she was a CR. She doesn't have the LVSI now. She had a big 6cm tumor that vanished and you're gonna perseverate on the presence of some cells that the pathologist saw pre-chemo, cells which also vanished? Doesn't totally compute.

                    Also, don't trust the LVSI readings from the pathologists anyways, least not maybe to hang one's entire clinical decision hat on. Perhaps as many as one out of three or four of those reads, negative or positive, will be read the opposite way by a different pathologist.
                     

                    medgator

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                      cT3N0 disease s/p mastectomy. I would not irradiate, unless LVSI noted.
                      ER 10%, pr and her 2 negative G3. Pretty close to a triple negative imo. I would treat, or at least consider repeating the receptors on the full specimen and treating if triple neg in this 41 y/o pt.


                      I've treated several triple neg mastectomy recurrences over the years in patients who weren't sent up front, and I'm sure there are several that never get sent to me at all when they met out elsewhere at the time of local recurrence
                       
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                      evilbooyaa

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                        Do you believe that she was clinically node negative? How strongly do you believe that? I am not very inclined to believe that biopsy result.

                        And, yes, I would be more inclined to think of this as a triple negative breast cancer with an ER of 10% and a pCR to NAC: Low ER+ Breast Cancer: Is This a Distinct Group?

                        So I'm approaching this as much more of a clinically node positive triple negative cancer in a 41 yo.

                        Even if you say, well she's a T3N0, the data for omitting PMRT is T3N0 cases frankly isn't great. The Nagar study shows a good benefit to PMRT in these patients, although it's true nobody with a pCR recurred on that study. I will look at other risk factors rather than just say all cT3N0 can avoid PMRT. In this case, she has multiple other risk factors that I really think, when added together, make PMRT a no-brainer in this situation. At the very least, I think this warrants a discussion with the patient and she should be offered treatment if she wants it even if you don't think it's really necessary.

                        I'm assuming this was a grade 3. Was there LVSI? Margins?

                        It was not palpable, I'm assuming, and only identified radiographically and biopsy was subsequently negative, I'd count her as node negative. Unless there was treatment effect in the nodes at time of surgery. Not all enlarged LNs on US are pathologic. Yes we rely on fatty hilum, presence of cortex, etc. to make judgement calls on US, but we get biopsy because those results are not 100% and we don't want to overtreat patients by calling any radiographically suspicious LN to be positive.

                        While ER of 1% is frequently treated as being negative, and I suppose some make the argument that even 10% is negative, I wouldn't push that. Med oncs give anti-hormonal to anyone with > 1%.

                        Data for omitting PMRT in cT3N0 is reasonable. If this was pT3N0 yes I'd be hard pressed to avoid PMRT in a 41 year old. But it's not, and pT3N0 is not nearly the slam dunk (IMO, haven't reviewed the literature comparatively in sometime) that pN+ is.

                        Now, if she was ypT3N0, then yes, absolutely she needs radiation IMO.

                        What other risk factors does this patient have? Besides age and concern for potentially a phenotype of TNBC (which is not well proven, IMO, that 10% ER+= TNBC)? We don't know grade or initial LVSI (which I agree with scarb that in setting of pCR, does not matter).

                        I'm not against a discussion with the patient about pros/cons of radiation, but this is not a situation that I can guarantee she will actually benefit from radiation.

                        Very reasonable to re-test markers as noted above on full specimen.
                         
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                        scarbrtj

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                          ER 10%, pr and her 2 negative G3. Pretty close to a triple negative imo. I would treat, or at least consider repeating the receptors on the full specimen and treating if triple neg in this 41 y/o pt.
                          I know I'm sounding like a broken record but TNBC patients who have CRs to NAC have better prognoses than non-TNBC patients who have partial responses.
                           

                          medgator

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                            I know I'm sounding like a broken record but TNBC patients who have CRs to NAC have better prognoses than non-TNBC patients who have partial responses.
                            And we have level I evidence to suggest an OS benefit for PMRT in early stage TNBC getting chemotherapy. Which do you believe?
                             

                            scarbrtj

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                              And we have level I evidence to suggest an OS benefit for PMRT in early stage TNBC getting chemotherapy. Which do you believe?
                              Heh. Was that the Wuhan trial or something. Don't know if they broke it down by NAC CRs or not. But if they did, and that data were to refute the near orgy of data we have now on "good prognosis TNBC" (when there's a CR), I'd believe the orgy I guess. TNBC sucks and is scary. Except with a CR.

                              EDIT: We have to keep in mind these pCR patients are kinda rare. MDACC calc tells us, going in, the lady only had a ~2% chance of being a pCR. But once you're in that pCR T0N0 cohort, it's just a whole different cohort.
                               
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                              Palex80

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                                I would irradiate.

                                Response to neoadjuvant chemo is not proven to be a factor that you may safely use to decide on indication to irradiate or not.

                                The next questions for those that would irradiate... what would you irradiate?
                                 
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                                scarbrtj

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                                  I would irradiate.

                                  Response to neoadjuvant chemo is not proven to be a factor that you may safely use to decide on indication to irradiate or not.

                                  The next questions for those that would irradiate... what would you irradiate?
                                  Can y'all tell me what the "proven" factors are to irradiate in this case? (First we have to agree what this case is! TNBC? pT0N0? cN1?) "Proven" is a big word to be such a small word.

                                  She has an expander and is reconstructed. We all know that ups the ante for XRT morbidity. And it's not like XRT is zero morbidity to start with (dramatic link). Even in the best of cases, e.g., in the recent ENI breast trials, the lung morbidity risk is ~5% and lymphedema risks ~10%... when doing ENI. Now add in the potential reconstruction toxicity which ups recon-associated toxicity risks at least 10-20%...

                                  So I guess irradiate everywhere except the chest wall region, which is where her recurrence risk is ~3-5% (based on literally thousands of patients at this point), because the risk/benefit ratio is too fraught. I guess irradiate her axilla where her recurrence risk is ~1%?

                                  The math doesn't look great.
                                   

                                  evilbooyaa

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                                    Can y'all tell me what the "proven" factors are to irradiate in this case? (First we have to agree what this case is! TNBC? pT0N0? cN1?) "Proven" is a big word to be such a small word.

                                    She has an expander and is reconstructed. We all know that ups the ante for XRT morbidity. And it's not like XRT is zero morbidity to start with (dramatic link). Even in the best of cases, e.g., in the recent ENI breast trials, the lung morbidity risk is ~5% and lymphedema risks ~10%... when doing ENI. Now add in the potential reconstruction toxicity which ups recon-associated toxicity risks at least 10-20%...

                                    So I guess irradiate everywhere except the chest wall region, which is where her recurrence risk is ~3-5% (based on literally thousands of patients at this point), because the risk/benefit ratio is too fraught. I guess irradiate her axilla where her recurrence risk is ~1%?

                                    The math doesn't look great.

                                    Can I just request that we, as a forum, not go down the bolded rabbit hole again. I would like to not 1) have a pounding headache and 2) want to pull the trigger on stopping people from being able to post im a specific thread (known as a thread ban)

                                    On topic - I'm not radiating pT2N0 TNBCs post-mastectomies routinely. Why are people saying ER 10% is triple negative? Every single trial defining TNBC has generally used a cut-off of 1%. All patients with ER 10% disease are getting anti-hormonal therapy.
                                     
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                                    scarbrtj

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                                      On topic - I'm not radiating pT2N0 TNBCs post-mastectomies routinely.
                                      Technically NCCN guidelines even allow for PMRT in T1N0 young patients with high risk features like extensive LVSI plus TNBC; and on request I do it in the non-CR TNBC patients that wouldn't be "typical" PMRT patients. Admittedly I don't get a lot of requests. And I don't see a huge difference in countenancing PMRT for any case where the tumor is, say, 2.1 cm in diameter but not countenancing PMRT ever if the tumor were, say, 1.9 cm in diameter.
                                       

                                      KHE88

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                                        Scarb, I do not have a randomized phase 3 trial to support radiation in this patient. However, you do not have one to support omitting it. Whom should the onus be on?

                                        Risk factors here:
                                        Age < 45
                                        Luminal B AT LEAST, but I would tend to think more as triple negative.
                                        High grade
                                        T3 disease
                                        No ALND (MSKCC nomogram risk of sentinel mets is 78% assuming no LVSI -- also worth noting that they use a cutoff of 10% to classify as ER-!)
                                        So, I think we can call this ER- as a risk factor as well.
                                        And obviously LVSI if present.

                                        A radiographically suspicious ipsilateral 2 cm node that shrinks with chemo? What's the false negative rate on a ultrasound guided axillary biopsy? Evaluation of axillary involvement by ultrasound-guided lymph node biopsy: A prospective study
                                        Hmmm...

                                        This is a gray area for sure because there's not great data for this specific scenario -- some seem to think there is? Where? We can piece together bits and pieces from multiple studies to try and approximate risk. But with questionable staging, TNBCish histology, and multiple risk factors I would err on the side of treatment in this young woman. With modern techniques including DIBH and 3D planning, we know the risk of long term heart, lung, and secondary cancer toxicity is < 1%. Cosmetic outcome in the setting of implant based reconstruction is certainly a much higher risk, but the patient can make that call. My recommendation would be for treatment.
                                         
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                                        Bequerel

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                                          I’m surprised to see so much debate. Young women with cT3N0 TNBC (10% was ER cutoff for older trials if you read paper supplements) always get PMRT with RNI regardless of response in my clinic. This lady possibly have cN1..makes decision even easier. I’m all in on trying to omit RT with old ladies, APBI when indicated and hypofractionating everything, but I don’t try to get cute with these young patients. If you’ve been practicing long enough, we all have heartbreaking stories of young moms dying from TNBC and I don’t want to be playing armchair quarterback wondering if my RNI could’ve prevented mets. There’s plenty of data to argue in circles given her pCR, but this is the type of patient that I’d error on the side of “over-treatment”.
                                           
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                                          scarbrtj

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                                            Scarb, I do not have a randomized phase 3 trial to support radiation in this patient. However, you do not have one to support omitting it. Whom should the onus be on?
                                            I suppose you've been taking hydroxychloroquine prophylactically ;) What can it hurt?
                                            EDIT
                                            But in fact if you want randomized data there is that mild, niggling trend toward worse survival in pN0 with PMRT
                                            4nLunoH.png

                                            A radiographically suspicious ipsilateral 2 cm node that shrinks with chemo? What's the false negative rate on a ultrasound guided axillary biopsy
                                            Don't think he said it "shrunk." He said it "normalized." You know. It was Abby Normal before I guess lol. Whatever normalized means. I don't know. Lymph nodes can get a little inflamed from a breast primary, seen that plenty 'o times where we were fully expecting positive nodes and they weren't.
                                            But with questionable staging,
                                            Questionable??? How. This all seems by the book standard of care stuff.
                                            we know the risk of long term heart, lung, and secondary cancer toxicity is < 1%.
                                            Ooh. I don't think so. I don't "know" that. A bunch of relatively modern (the ENI trials I alluded to) data says the lung risk is in that 4% neighborhood and the lymphedema risk is of course higher than that. I'm with you on 2nd cancer and heart risk. And on the lung risk if you don't do ENI. But you said you're "balls to walls" re: ENI. Don't care how modern the tx is, with ENI you have a higher lung tox risk. Especially with IMNs.

                                            10% was ER cutoff for older trials if you read paper supplements
                                            <10% though right? Not ≤10%. I mean I think the 10% is code for "it's low but it's not negative by any stretch."
                                             
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                                              I’m surprised to see so much debate. Young women with cT3N0 TNBC (10% was ER cutoff for older trials if you read paper supplements) always get PMRT with RNI regardless of response in my clinic. This lady possibly have cN1..makes decision even easier. I’m all in on trying to omit RT with old ladies, APBI when indicated and hypofractionating everything, but I don’t try to get cute with these young patients. If you’ve been practicing long enough, we all have heartbreaking stories of young moms dying from TNBC and I don’t want to be playing armchair quarterback wondering if my RNI could’ve prevented mets. There’s plenty of data to argue in circles given her pCR, but this is the type of patient that I’d error on the side of “over-treatment”.
                                              Agreed. There’s plenty of Level 1 evidence supporting treating cT3/4 and/or LN+ breast cancers with PMRT. Add in the age, grade, incongruent node biopsy result, and biology looking “like” triple negative, you just treat and not think too much about it.

                                              Radiation is the special sauce of breast cancer treatment. It works. It’s not really physiologically toxic. I have full faith that if this was your wife or sister, or you.... you’d be giving/getting radiation.
                                               
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                                              scarbrtj

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                                                incongruent node biopsy result,
                                                Wait... how was it incongruent...
                                                (And what the hell is a "core biopsy" on a node, and placing a clip at time of core biopsy, all about.)
                                                I mean I assume they actually removed that node, and this is the reason Reaganite doesn't mention Mr. 2cm node again later. I assume.
                                                As I said the node story is... confusing (thanks Reaganite!)... but not probative, as the lawyers say.
                                                 
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                                                evilbooyaa

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                                                  Agreed. There’s plenty of Level 1 evidence supporting treating cT3/4 and/or LN+ breast cancers with PMRT. Add in the age, grade, incongruent node biopsy result, and biology looking “like” triple negative, you just treat and not think to much about it.

                                                  Radiation is the special sauce of breast cancer treatment. It works. It’s not really physiologically toxic. I have full faith that if this was your wife or sister, or you.... you’d be giving/getting radiation.

                                                  There is plenty of data for STAGE III patients (7th edition AJCC) getting PMRT.

                                                  T3N0 was not stage III in 7th edition.

                                                  Let's discuss the Nagar study as @KHE88 so well alluded to: Local-Regional Recurrence With and Without Radiation Therapy After Neoadjuvant Chemotherapy and Mastectomy for Clinically Staged T3N0 Breast Cancer

                                                  Yes, in all comers PMRT is a clear winner.

                                                  "None of the 13 patients who achieved pCR had a LRR. Due to the limited number of LRR events, a multivariate analysis was not conducted. "

                                                  That being said, in the no RT group 75% of patients were ypN0 and still had a 24% LRR. Maybe my scale for radiating cT3N0 is a little off-base. Maybe even if she is ER+/PR-/Her2- (as I believe) I should still be doing RT.

                                                  Maybe I'm wrong about this (certainly feels like I am as I look at the imbalance in opinions and the owners of those opinions in this thread). Might need to take a deep dive in the cT3N0 data again.
                                                   
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                                                  KHE88

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                                                    I suppose you've been taking hydroxychloroquine prophylactically ;) What can it hurt?
                                                    EDIT
                                                    But in fact if you want randomized data there is that mild, niggling trend toward worse survival in pN0 with PMRT
                                                    4nLunoH.png


                                                    Don't think he said it "shrunk." He said it "normalized." You know. It was Abby Normal before I guess lol. Whatever normalized means. I don't know. Lymph nodes can get a little inflamed from a breast primary, seen that plenty 'o times where we were fully expecting positive nodes and they weren't.

                                                    Questionable??? How. This all seems by the book standard of care stuff.

                                                    Ooh. I don't think so. I don't "know" that. A bunch of relatively modern (the ENI trials I alluded to) data says the lung risk is in that 4% neighborhood and the lymphedema risk is of course higher than that. I'm with you on 2nd cancer and heart risk. And on the lung risk if you don't do ENI. But you said you're "balls to walls" re: ENI. Don't care how modern the tx is, with ENI you have a higher lung tox risk. Especially with IMNs.


                                                    <10% though right? Not ≤10%. I mean I think the 10% is code for "it's low but it's not negative by any stretch."

                                                    A meta-analysis of all-comers with pN0 disease? With an axillary dissection? This lady did not have an axillary dissection!

                                                    Who knows what her axillary disease status is! Either up front or after NAC!

                                                    You cannot absolutely say that she was both cN0 and pN0! Both are questionable in my book. Certainly not zero.

                                                    Long term incidence pneumonitis < 1%.
                                                    Weren't talking about lymph edema, but severe rates 1-5%.
                                                    Regardless, LOW
                                                    Which would you rather have? Pneumonitis and lymphedema or an axillary recurrence and likely systemic disease?

                                                    It doesn't matter if it's <10% or <= 10%. That's asinine to use a hard cutoff like that and say, well it was 10.001% so that's totally ER+, but this case was 9.999% so we can basically call that TNBC. Plus, you have to wonder how that reported 10% number is generated.

                                                    I think you are putting WAY too much faith in a pCR and the ability of chemo alone to clear what very likely may have been gross disease in her axilla, let alone microscopic disease.
                                                     
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                                                    medgator

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                                                      Heh. Was that the Wuhan trial or something. Don't know if they broke it down by NAC CRs or not. But if they did, and that data were to refute the near orgy of data we have now on "good prognosis TNBC" (when there's a CR), I'd believe the orgy I guess. TNBC sucks and is scary. Except with a CR.
                                                      Not sure that using chemo response to determine xrt decision has been validated for mainstream use.... Haven't checked in a little while but nccn discusses this also
                                                       

                                                      scarbrtj

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                                                        You cannot absolutely say that she was both cN0 and pN0!
                                                        Well, what stage is her stage going to be at the tumor registry. Or on a study. We can't "absolutely" say anything, maybe, ever.
                                                        It doesn't matter if it's <10% or <= 10%. That's asinine to use a hard cutoff like that and say, well it was 10.001% so that's totally ER+, but this case was 9.999% so we can basically call that TNBC. Plus, you have to wonder how that reported 10% number is generated.
                                                        Yeah, I'm down for some oncological metacognition. Call the pathologist, if you trust him; see what he says.
                                                        I think you are putting WAY too much faith in a pCR and the ability of chemo alone to clear what very likely may have been gross disease in her axilla, let alone microscopic disease.
                                                        Well if the surgeons can consider tossing the scalpel after pCRs, we had best be prepared to toss the beam.
                                                         

                                                        KHE88

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                                                          Maybe I'm wrong about this (certainly feels like I am as I look at the imbalance in opinions and the owners of those opinions in this thread). Might need to take a deep dive in the cT3N0 data again.

                                                          Is anybody here arguing strongly against radiating except the scarb? Seems like there is a pretty good consensus that she needs treatment.
                                                           

                                                          scarbrtj

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                                                            2 cm with thickened cortex and no fatty hilum, that regained normal morphology following chemo and response. I don’t know. I’ve seen US guided biopsies miss the cancer a few times.
                                                            I mean, yeah, assuming the biopsy was a false negative it was incongruent. Else, it was negative when thickened and looked weird, and negative when it looked normal.
                                                             
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                                                            KHE88

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                                                              Well, what stage is her stage going to be at the tumor registry. Or on a study.

                                                              Yeah, I'm down for some oncological metacognition. Call the pathologist, if you trust him; see what he says.

                                                              Well if the surgeons can consider tossing the scalpel after pCRs, we had best be prepared to toss the beam.

                                                              So is this like Schrodinger's cat or something? Better not look inside the box!

                                                              It doesn't matter what her stage by the book is. Because the book stages her as a cT3N0 does not mean she is actually node negative. You cannot possibly know that. It's like that game we'd play with FIGO staging in GYN where we know that there's a positive lymph node because of a PET scan but we are just supposed to ignore it. Hey, she's stage 1 bro! Just sayin...
                                                               

                                                              Mandelin Rain

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                                                                I mean, yeah, assuming the biopsy was a false negative it was incongruent. Else, it was negative when thickened and looked weird, and negative when it looked normal.
                                                                True, I haven’t looked at the images but I’m assuming it looked weird enough to biopsy. There was another that looked weird but wasn’t biopsied. We clearly don’t have all the info, but it’s not like a premenopausal woman with a 6 cm grade 3 cancer having nodal mets is unusual. High pre test probability.
                                                                 

                                                                scarbrtj

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                                                                  So is this like Schrodinger's cat or something? Better not look inside the box!

                                                                  It doesn't matter what her stage by the book is. Because the book stages her as a cT3N0 does not mean she is actually node negative. You cannot possibly know that. It's like that game we'd play with FIGO staging in GYN where we know that there's a positive lymph node because of a PET scan but we are just supposed to ignore it. Hey, she's stage 1 bro! Just sayin...
                                                                  Think Bayesianistically. In the GYN example, the PET positivity raises the pre-test probability.
                                                                  There is nothing I see here that raises her pre-rest probability for being pN+ and instead seemingly multiple lines of evidence to lower it.

                                                                  a 6 cm grade 3 cancer having nodal mets is unusual.
                                                                  She was grade 3?
                                                                   

                                                                  evilbooyaa

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                                                                    Is anybody here arguing strongly against radiating except the scarb? Seems like there is a pretty good consensus that she needs treatment.

                                                                    I am (was?) in the camp of trying to avoid radiation in her at initial response, but it seems weird to be arm in arm with scarb of all people against the rest of those who have posted in this thread.

                                                                    @Reaganite any presence of treatment effect in the lymph nodes?

                                                                    I suppose, if we're going to treat a negative biopsy in this patient as a false negative, then why biopsy the node at all?

                                                                    Also, let's be real, big difference on correlative ability of US to identify a suspicious LN and PET/CT. If we treated every US suspicious LN (not even MRI in this patient per OP) as being positive we'd all be a lot busier doing PMRT.
                                                                     

                                                                    scarbrtj

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                                                                      I am (was?) in the camp of trying to avoid radiation in her at initial response, but it seems weird to be arm in arm with scarb of all people against the rest of those who have posted in this thread.

                                                                      @Reaganite any presence of treatment effect in the lymph nodes?

                                                                      I suppose, if we're going to treat a negative biopsy in this patient as a false negative, then why biopsy the node at all?

                                                                      Also, let's be real, big difference on correlative ability of US to identify a suspicious LN and PET/CT. If we treated every US suspicious LN (not even MRI in this patient per OP) as being positive we'd all be a lot busier doing PMRT.
                                                                      I'm your broken clock and yet only my first time today of being correct...
                                                                       

                                                                      Reaganite

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                                                                        Wait... how was it incongruent...
                                                                        (And what the hell is a "core biopsy" on a node, and placing a clip at time of core biopsy, all about.)
                                                                        I mean I assume they actually removed that node, and this is the reason Reaganite doesn't mention Mr. 2cm node again later. I assume.
                                                                        As I said the node story is... confusing (thanks Reaganite!)... but not probative, as the lawyers say.

                                                                        Hah, sorry, man was away from the computer this whole time! To clarify, 2 enlarged nodes on pre chemo ultrasound and CT scan, 2 cm and 1.5 respectively. The 2cm node was biopsied (negative) and they placed a clip in the node at the time of biopsy. Post neo, both nodes shrank by about 50% and they specifically mention in imaging reports that the 1.5cm node assumed a "normal" appearance with fatty hilum. At time of surg, a sentinel node was recovered which turned out to be the originally biopsied and clipped node. The other previously enlarged node was not removed.
                                                                         

                                                                        scarbrtj

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                                                                          Hah, sorry, man was away from the computer this whole time! To clarify, 2 enlarged nodes on pre chemo ultrasound and CT scan, 2 cm and 1.5 respectively. The 2cm node was biopsied (negative) and they placed a clip in the node at the time of biopsy. Post neo, both nodes shrank by about 50% and they specifically mention in imaging reports that the 1.5cm node assumed a "normal" appearance with fatty hilum. At time of surg, a sentinel node was recovered which turned out to be the originally biopsied and clipped node. The other previously enlarged node was not removed.
                                                                          This is case presentation by sfumato technique lol. Prob no needles moving. What was the grade? And LVSI? PNI? Her Zodiac?
                                                                          All mental masturbation aside, if it was your wife, she’d be getting radiation. That’s all patients want from you.
                                                                          I'm over here non-onanistically not offering the RT to the loved ones... IN THIS HIGHLY PARTICULAR CASE.
                                                                           
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                                                                          KHE88

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                                                                            Think Bayesianistically. In the GYN example, the PET positivity raises the pre-test probability.
                                                                            There is nothing I see here that raises her pre-rest probability for being pN+ and instead seemingly multiple lines of evidence to lower it.


                                                                            She was grade 3?

                                                                            So you are just basing this all on the analysis of the NSABP NAC trials. The one where TNBC status wasn't teased out? And just ignoring the Chinese TNBC data?

                                                                            So, what would it take for you to radiate?
                                                                            If ER were 9% would that be enough?1%? 0%?
                                                                            pCR = no radiation no matter what ever? Even for a lovely multifocal 6.9 cm inner quadrant TNBC grade 3 w/ LVSI in a 29 year old with a pCR after chemo and pembro? She refused axillary staging btw, and nothing felt on exam so by the book she is cN0 and had a pCR!

                                                                            The dogma in breast radiation amazes me. Especially with such awful data. I've identified 6+ risk factors in this lady. How much does each one raise the risk exactly? Who knows! But don't lose sight of the forest for the trees IMO.

                                                                            Lot of unknowns here!

                                                                            "It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so. – Mark Twain.
                                                                            Which of course wasn't so.
                                                                             

                                                                            Mandelin Rain

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                                                                              This is case presentation by sfumato technique lol. Prob no needles moving. What was the grade?

                                                                              I'm over here non-onanistically not offering the RT to the loved ones... IN THIS HIGHLY PARTICULAR CASE.
                                                                              I honestly don’t believe you. You’re a smart guy and this could be aptly termed a “borderline” case (though would have been Firmly included in the Danish). You realize the risk of under treatment is huge and of over treatment is minimal. Everyone on this board is treating this 41 year old if it’s you or the mother of your kids.

                                                                              Assuming she’s a competent person, she likely felt this grow to 6cm over a couple months, it has minimal staining for ER, and CR to chemo. This is an aggressive ass cancer. Treat it as such.
                                                                               

                                                                              KHE88

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                                                                                I honestly don’t believe you. You’re a smart guy and this could be aptly termed a “borderline” case (though would have been Firmly included in the Danish). You realize the risk of under treatment is huge and of over treatment is minimal. Everyone on this board is treating this 41 year old if it’s you or the mother of your kids.

                                                                                Assuming she’s a competent person, she likely felt this grow to 6cm over a couple months, it has minimal staining for ER, and CR to chemo. This is an aggressive ass cancer. Treat it as such.

                                                                                I mean, we've spent threads basically arguing whether the air conditioning in the vault modulates the intensity of the radiation and is thus IMRT. Sometimes I wonder where all this angst over breast cases comes from. And it's not just the scarb. I think we've all encountered someone in training or practice that throws a fit on a particular nuance of breast radiation, be it "IMRT" , boosts, prone vs. DIBH, high tangents vs. breast only, nodes +/- IMC, bolus, etc, and sometimes forget that it's an art, the NCCN guidelines are a total cluster----, we're never going to have a perfect answer, and have to put all the info we have together to make the best guess and each case is going to be a little bit different.

                                                                                Can we justify omitting PMRT here? Sure. I think if we got pulled into court later we could legally get ourselves out of trouble. However, I think it's clear the mental gymnastics to justify treating are a lot easier than to justify omitting.
                                                                                 
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                                                                                radmonckey

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                                                                                  If a node is biopsied negative up front and there is no demonstrated treatment effect on pathology (our pathologists typically comment on this), that patient is node negative in my book.

                                                                                  So a patient received a highly immunosuppressive agent and a lymph node shrank? Interesting story.

                                                                                  If you are going to sell me on pmrt here, it's not going to be on the nodal status.

                                                                                  Also, I think some are underselling the toxicity of PMRT here.
                                                                                   
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                                                                                  Mandelin Rain

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                                                                                    if she was 70 years old with a 5 cm, low grade 90% ER+ we wouldn’t be having this discussion. Node or otherwise. But yes, in that case I’d be willing to bet my treatment recommendation on the US guided bx and subsequent removal of one of the two suspicious nodes.
                                                                                     

                                                                                    scarbrtj

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                                                                                      So you are just basing this all on the analysis of the NSABP NAC trials. The one where TNBC status wasn't teased out? And just ignoring the Chinese TNBC data?

                                                                                      So, what would it take for you to radiate?
                                                                                      If ER were 9% would that be enough?1%? 0%?
                                                                                      pCR = no radiation no matter what ever? Even for a lovely multifocal 6.9 cm inner quadrant TNBC grade 3 w/ LVSI in a 29 year old with a pCR after chemo and pembro? She refused axillary staging btw, and nothing felt on exam so by the book she is cN0 and had a pCR!
                                                                                      The TNBC "badness" appears to be a red herring in the setting of pCR based on the data from, what I know of, around 40,000-plus patients (see below). In other words, as I alluded to earlier, I think this thought process has not permeated the minds of rad oncs: TNBC is not bad 100% of the time.
                                                                                      this could be aptly termed a “borderline” case
                                                                                      Definitely. And kind of rare. As I said before, MDACC calculator would've predicted a ~2% chance for total pCR for her.
                                                                                      This is an aggressive ass cancer.
                                                                                      So this is the disconnect. I believe quite strongly that this is not an "aggressive ass cancer" and she has a ~95% 5y OS and maybe ~10% risk of any event, distant or local, over the next 5 years.
                                                                                       

                                                                                      Mandelin Rain

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                                                                                        I mean, we've spent threads basically arguing whether the air conditioning in the vault modulates the intensity of the radiation and is thus IMRT. Sometimes I wonder where all this angst over breast cases comes from. And it's not just the scarb. I think we've all encountered someone in training or practice that throws a fit on a particular nuance of breast radiation, be it "IMRT" , boosts, prone vs. DIBH, high tangents vs. breast only, nodes +/- IMC, bolus, etc, and sometimes forget that it's an art, the NCCN guidelines are a total cluster----, we're never going to have a perfect answer, and have to put all the info we have together to make the best guess and each case is going to be a little bit different.

                                                                                        Can we justify omitting PMRT here? Sure. I think if we got pulled into court later we could legally get ourselves out of trouble. However, I think it's clear the mental gymnastics to justify treating are a lot easier than to justify omitting.
                                                                                        You have to perseverate about something.

                                                                                        Breast cancer radiation is too easy. If you’re seeing the patient you “probably” should be treating the patient.

                                                                                        How do you bill yourself as an expert if you can’t divine excruciating nuance to that paradigm?
                                                                                         

                                                                                        Mandelin Rain

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                                                                                          So this is the disconnect. I believe quite strongly that this is not an "aggressive ass cancer" and she has a ~95% 5y OS and maybe ~10% risk of any event, distant or local, over the next 5 years.
                                                                                          She’s not an 80 year old who neglected a slowly progressive mass for years until it became 6 cm.

                                                                                          I’m making an assumption that she’s a reasonably intellegent and hygienic person who bathes themselves and runs her hand over her breast at least a few times a week. My “guess” is this grew pretty fast. That enters into my “aggressive” phenotype presumption. Unknown if she had a previous mammogram or not.
                                                                                           
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