53 year old female with 3cm breast mass. Undergoes lumpectomy and sentinel node bx. Path shows triple negative idc with neg margins, sentinel node negative. Pt completes ac + t chemo followed by whole breast irradiation one year ago. Pt seen by my retiring partner a few weeks ago with new palpable 2cm axillary mass. Fna shows idc. Of note, this node is basically splitting the original superior border of the tangents (clinical determination based on the location of the mass relative to the upper border of hyperpigmentation of the treated breast). Pt seen by surgeon who performs (at the request of my partner) a wide excision of the mass only then orders a pet/ct...so no pre surgery imaging. Pet is negative. Path shows a 2cm lymph node with multiple "positive margins." Now surgeon sends back for rt and my retiring partner wants me to take over case...he's told surgeon we will treat axilla above original tangents plus sclav with boost to original site of disease. Im obviously nervous about this for several reasons...no preop imaging so cant localize original extent of nodal disease, portion of node overlaps prior field, etc. Im leaning towards sending her back to surgeon for true dissection to clear the axilla but am obviously nervous about all the possible political implications (surgeon and rad onc have already agreed on this approach and im new to area ). Not comfortable with radiating at this time though. Thoughts?
breast case
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deleted4401
Gotta love private practice and the politics that come along with it. Maybe talk to your partner about at least discussing a dissection and then if you can convince him, have him call the referring doctor?
Otherwise, you're stuck with the plan you outlined.
Otherwise, you're stuck with the plan you outlined.
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The question is why the wide excision of the mass resulted in multiple positive margins. Is the lesion in the proximity of vessels or nerves in the axilla, which the surgeon would like / has to spare, or did he simply "screw up"?
Although I am all for acquiring wide surgical margins before RT is delivered, one should not underestimate the risk of lymphedema associated with a complete surgical axillary clearance. This patient has already undergone two axillary procedures and in the end will have a lot of cumulative radiation dose delivered into her axillary tissue,
Perhaps the surgeon could ommit complete axillary clearance (since the PET is negative and the patient is going to get axillary RT anyhow) and simple try to acquire the desire wide margin around the involved node?
Although I am all for acquiring wide surgical margins before RT is delivered, one should not underestimate the risk of lymphedema associated with a complete surgical axillary clearance. This patient has already undergone two axillary procedures and in the end will have a lot of cumulative radiation dose delivered into her axillary tissue,
Perhaps the surgeon could ommit complete axillary clearance (since the PET is negative and the patient is going to get axillary RT anyhow) and simple try to acquire the desire wide margin around the involved node?
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Repeat irradiation of the axilla is problematic.
I'd recommend complete axillary dissection, as the other axillary nodes are at risk. Follow this with chemotherapy and RT to the supraclav, matching above the previous breast tangent fields.
Best of luck.
I'd recommend complete axillary dissection, as the other axillary nodes are at risk. Follow this with chemotherapy and RT to the supraclav, matching above the previous breast tangent fields.
Best of luck.
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Palex brings up a good point: why were there several positive margins? My guess would be extracapsular extension that was not resected. If this is the case, the axilla should be cleared surgically based on risk factors for recurrence in the primary setting. The question then becomes how much radiation did the axilla receive with the previous radiation, and how well can that be matched to a new field. I would probably still try to do it. Then add on top of that supraclavicular nodal coverage. The patient will almost certainly end up with lymphedema, maybe even pretty severe lymphedema, as well as other side effects.
However, long term follow up from Danish 82b+82c gives a grim prognosis for locoregional recurrence patients, with mean time to DM ~2 years and 80% DM rate by 10 years (http://www.sciencedirect.com/science/article/pii/S0167814006001484). I look at that, and the fact that she's a fairly young triple negative patient. If this cancer does not take her life in the next five years, she is lucky. As a result, in the academic setting I would shoot as hard as I can for cure via surgery, radiation, and chemo.
Refer to medical oncology for consideration of second line chemotherapy. This can be extrapolated from the metastatic setting (for example Ixabepilone Plus Capecitabine: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903325/). The disease that was cut out on the last surgery should be re-stained for ER/PR/Her2 just to be certain of the diagnosis and the hormonal status. I will assume she's up to date on her mammography otherwise. It would be silly to miss a small new primary or residual disease within the breast.
However, long term follow up from Danish 82b+82c gives a grim prognosis for locoregional recurrence patients, with mean time to DM ~2 years and 80% DM rate by 10 years (http://www.sciencedirect.com/science/article/pii/S0167814006001484). I look at that, and the fact that she's a fairly young triple negative patient. If this cancer does not take her life in the next five years, she is lucky. As a result, in the academic setting I would shoot as hard as I can for cure via surgery, radiation, and chemo.
Refer to medical oncology for consideration of second line chemotherapy. This can be extrapolated from the metastatic setting (for example Ixabepilone Plus Capecitabine: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903325/). The disease that was cut out on the last surgery should be re-stained for ER/PR/Her2 just to be certain of the diagnosis and the hormonal status. I will assume she's up to date on her mammography otherwise. It would be silly to miss a small new primary or residual disease within the breast.
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Yup. Seems odd. Either a crappy, piecemeal resection of a big node, or some wicked ECE in the axilla.
D
deleted4401
Hmm. I just took it to mean an excisional biopsy. That's what some of the surgeons do here for breast masses that they excise without a biopsy. The path comes back as "infiltrating ductal carcinoma, with invasive disease extending to the margins." He just plucked some tissue out, didn't seem like an oncologic procedure was performed.
thank you for the responses. I guess this is the world of private practice that I always heard about...The "positive margins" thing is a little strange to me. Is it ece? Did he cut through the node? Was the node adherent to a vessel? Who knows. No preop imaging was done, and I can't get the op report as surgeon is out of town for next 2 weeks. Tried to call the pathologist, but he too is unavailable. I guess we'll see what happens, but glad to hear most agree with my further surg rec if possible (assuming this wasn't disease that was adherent to a vessel or something of that nature as palex brought up).
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Having reexcised people for axillary recurrences after negative sentinel lymph nodes, this is of interest to me.
As others have noted, its difficult to say what exactly was found and done surgically in this case.
Perhaps he only excised the involved node. Some surgeons "defat" the node very meticulously before sending it to pathology. Nice for the pathologist, but can leave disease behind if there is ECE and the "defatting" was done in situ (rather than on the back table).
And I'm not sure what a WLE is here. Its not really a term we use in relation to the axilla. I would assume it meant the involved node and the local fat around it but leaving the bulk of the axillary fat pad. Thus the term "multiple positive margins" isn't very helpful without knowing exactly what came out and why. Is "WLE" 2 mm around the node, or 2 cm? I just don't know. If it was just the node, then there was ECE into the surrounding fat. How much fat was taken? We don't know. If the node was abutting or involving LT or TD nerves or axillary vein, most would not resect those but leaving them would risk a "positive margin".
Having the op note would be helpful if there was a comment about the integrity of the node. Did he cut through it? Was it stuck to something that he left behind (I've been in the delightful position of finding a node stuck to the axillary vein. Talk about sphincter control.)? A large malignant node, especially one previously biopsied (albeit usually with core), can be very necrotic and friable. They just fall apart in your hands/instruments like so much Cream of Wheat. Even with a good washout, you're never really sure if you got all of it out, although there isn't any data on whether those cells would survive and become a threat to the patient's health.
The temptation is to be very aggressive with such a young patient with bad disease but you have to ask, "at what cost"? If you cannot provide a survival benefit with RT, don't discount the very real morbidity of lymphedema. As you all have rightly noted, the addition of axillary RT to a full axillary dissection dramatically increases the LE rate. Women suffer with it; I don't use the word suffer lightly.
Since there is very little surgical data that supports increased OS with aggressive surgical axillary management (which is why it is being phased out in many areas, not in small part due to Z-011), I'd tend to favor either/or: clear the axilla surgically or axillary RT if there is evidence that it changes OS or LRR, not both. If pressed, I'd favor surgery over re-radiating the axilla.
Just my 2 cents as a dumb surgeon...(invited by one of you to come to your party ).
As others have noted, its difficult to say what exactly was found and done surgically in this case.
Perhaps he only excised the involved node. Some surgeons "defat" the node very meticulously before sending it to pathology. Nice for the pathologist, but can leave disease behind if there is ECE and the "defatting" was done in situ (rather than on the back table).
And I'm not sure what a WLE is here. Its not really a term we use in relation to the axilla. I would assume it meant the involved node and the local fat around it but leaving the bulk of the axillary fat pad. Thus the term "multiple positive margins" isn't very helpful without knowing exactly what came out and why. Is "WLE" 2 mm around the node, or 2 cm? I just don't know. If it was just the node, then there was ECE into the surrounding fat. How much fat was taken? We don't know. If the node was abutting or involving LT or TD nerves or axillary vein, most would not resect those but leaving them would risk a "positive margin".
Having the op note would be helpful if there was a comment about the integrity of the node. Did he cut through it? Was it stuck to something that he left behind (I've been in the delightful position of finding a node stuck to the axillary vein. Talk about sphincter control.)? A large malignant node, especially one previously biopsied (albeit usually with core), can be very necrotic and friable. They just fall apart in your hands/instruments like so much Cream of Wheat. Even with a good washout, you're never really sure if you got all of it out, although there isn't any data on whether those cells would survive and become a threat to the patient's health.
The temptation is to be very aggressive with such a young patient with bad disease but you have to ask, "at what cost"? If you cannot provide a survival benefit with RT, don't discount the very real morbidity of lymphedema. As you all have rightly noted, the addition of axillary RT to a full axillary dissection dramatically increases the LE rate. Women suffer with it; I don't use the word suffer lightly.
Since there is very little surgical data that supports increased OS with aggressive surgical axillary management (which is why it is being phased out in many areas, not in small part due to Z-011), I'd tend to favor either/or: clear the axilla surgically or axillary RT if there is evidence that it changes OS or LRR, not both. If pressed, I'd favor surgery over re-radiating the axilla.
Just my 2 cents as a dumb surgeon...(invited by one of you to come to your party
).
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You should still be able to get the OP report from the hospital as a medical provider; at the very least, the patient can request it, or her PCP and have them forward it to you.
While the pathologist who read the study may be unavailable, surely there are others in town at that facility who can shed some light on it (and drew the lucky straw to be working over the holidays).
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Not bad for a "dumb surgeon." . I appreciate the multi-disciplinary aspect to this discussion. I do agree, the op note would be extremely helpful in this situation, but I don't really have much to add to this discussion due to lack of any real experience. I just assumed we treat everything that comes in the door, especially if the referring physician asked me to .
. I appreciate the multi-disciplinary aspect to this discussion. I do agree, the op note would be extremely helpful in this situation, but I don't really have much to add to this discussion due to lack of any real experience. I just assumed we treat everything that comes in the door, especially if the referring physician asked me to .
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Not bad for a "dumb surgeon."
Perhaps this is where the disconnect between specialties comes from.
I consider it my job to send a patient for consultations with Med Onc/Rad Onc even if I don't think there is a role for adjuvant tx; it is not my job to keep up with the "latest and greatest" in your field. You guys are always pulling some random study out of Iceland or Outer Mongolia to justify RT.
But that being said, I don't send patients to Rad Onc because I think you "have to treat everything that comes in the door". On the contrary, I want you to avoid treating anyone who doesn't need it or won't benefit from it (ie, the super elderly). I want to do my due diligence in sending them to you but please don't think that I assume you need to treat everyone just because I referred them to you.
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I'm thinking / hoping that the "we treat everything that comes in the door" comment was made tongue-in-cheek.
Perhaps this is where the disconnect between specialties comes from.
I consider it my job to send a patient for consultations with Med Onc/Rad Onc even if I don't think there is a role for adjuvant tx; it is not my job to keep up with the "latest and greatest" in your field. You guys are always pulling some random study out of Iceland or Outer Mongolia to justify RT.
But that being said, I don't send patients to Rad Onc because I think you "have to treat everything that comes in the door". On the contrary, I want you to avoid treating anyone who doesn't need it or won't benefit from it (ie, the super elderly). I want to do my due diligence in sending them to you but please don't think that I assume you need to treat everyone just because I referred them to you.
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It was... hence the
Who knew you guys had a sense of humor.
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I do what I can.
Thank you for all the responses. Still waiting for the op report unfortunately, but will hopefully get it soon. Have another case for you...
47 y/o female with 5cm breast mass. Biopsy of mass=IDC, high grade, weakly ER/PR positive. U/S of axilla shows "nodes" (that's all report says), one of which is biopsied and returns as metastatic IDC. Patient undergoes 6 cycles of neoadjuvant ACT followed by lumpectomy and axillary LND (back in august). Final path shows 3cm of residual IDC in the breast and 3/10 axillary nodes positive, including 1 node measuring 1cm with ECE. Breast margin is within 1mm, so another retiring colleague of mine sends back for reexcision. 2 months later (october) patient undergoes mastectomy with no residual malignancy identified. Now I inherit this patient this week (over 2 months after her mastectomy), and her planning CT shows 2 enlarged right sided axillary lymph nodes measuring up to 1.5 cm in short axis diameter each. A very helpful surgeon on this board
has pointed out that these are usually reactive, although recurrence is a possibility given her chemo-refractory disease and multiple nodes + with ECE in spite of chemo. If a biopsy would take another month (I'm told there's a real chance it may d/t insurance reasons), would anyone treat without biopsying the nodes (either chalking them up to reactivity and leaving them alone or treating them as tumor and boosting)?
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Why are these nodes "suspicious"? Size criteria > 1 cm or architecture?
Reactive nodes even several months after surgery are not uncommon, especially if she has a medical device implant/tissue expander in there.
Not my call on the radiation obviously, but I'd suggest no definitive treatment until those nodes are biopsied percutaneously.
Seen waaaayyyyy too many of these post-op PET/CTs with the exact same thing which ends up almost always being benign.
BTW, little disturbing that it took them 2 months to reexcise her and another 2 months to get into see you. Who ARE these patients that would tolerate that? Mine are all up in arms if I can't operate on them within a week of initial consultation (which I generally can't but I did get guilted into operating the day after Christmas on several peeps).
Reactive nodes even several months after surgery are not uncommon, especially if she has a medical device implant/tissue expander in there.
Not my call on the radiation obviously, but I'd suggest no definitive treatment until those nodes are biopsied percutaneously.
Seen waaaayyyyy too many of these post-op PET/CTs with the exact same thing which ends up almost always being benign.
BTW, little disturbing that it took them 2 months to reexcise her and another 2 months to get into see you. Who ARE these patients that would tolerate that? Mine are all up in arms if I can't operate on them within a week of initial consultation (which I generally can't but I did get guilted into operating the day after Christmas on several peeps).
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I would like to have some more information on those "suspicious nodes" before starting treatment. Yes, it may delay treatment start, but if these are macroscopic lymph node mets, you need to have them operated on, as long as you stay on the curative pathway.
Perhaps a PET-CT first, followed by ultrasound guided biopsy would be the optimal way to do it. If she already has macroscopic recurrence in the axilla, you may get some more information from the PET-CT (she may have paraclavicular nodes or even distant metastasis in the mean time).
I would give this lady full nodal RT in addition to the chestwall RT as long as she stays in the curative pathway.
Perhaps a PET-CT first, followed by ultrasound guided biopsy would be the optimal way to do it. If she already has macroscopic recurrence in the axilla, you may get some more information from the PET-CT (she may have paraclavicular nodes or even distant metastasis in the mean time).
I would give this lady full nodal RT in addition to the chestwall RT as long as she stays in the curative pathway.
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1 month to get the biopsy done?
Tell her to hop on the I-10 and come here. We can have auth in 24 hours or less, I'll biopsy her the same day as our consult and I'll call her (and you) with results in 24-48 business hrs. If there is some real reason for trouble with auth, she can pay cash and we'll reimburse her when the insurance funds are paid.
This is how we roll.
Your institution is taking entirely too long to surgically and adjuvantly treat and biopsy these women, IMHO (based on my one sided view of what you've written above) and is operating below the SOC (not you or Rad onc).
Tell her to hop on the I-10 and come here. We can have auth in 24 hours or less, I'll biopsy her the same day as our consult and I'll call her (and you) with results in 24-48 business hrs. If there is some real reason for trouble with auth, she can pay cash and we'll reimburse her when the insurance funds are paid.
This is how we roll.
Your institution is taking entirely too long to surgically and adjuvantly treat and biopsy these women, IMHO (based on my one sided view of what you've written above) and is operating below the SOC (not you or Rad onc).
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Are you on chartrounds right now?
