breast difficult cases

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Kroll2013

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1- 53 years old patient that presented with nipple changes in the left breast.
breast mammography : round opacity, with micro calcifications, <1 cm retro-areolar.
biopsy showed micro-foci of high grade DCIS with diffuse micro calcifications.
she underwent a modified radical mastectomy with SLN.
pathology: 0/4 LN, Invasive Ductal carcinoma, high grade, 2.45 mm (pTa), associated with multifocal extensive intraductal component of comedy-necrosis ranging from 1cm to 2.5cm, nipple invasion is present, Paget present in the nipple, lobular cancerization present, negative margins, ER neg, PR neg, Her-2 +.

is Adjuvant radiation therapy to the Chestwall indicated ?


2- 54 yo lady without any comorbidities or past medical history who was diagnosed 4 months back with left breast cancer. She underwent a left subcutaneous nipple/skin sparing mastectomy, and SN Sampling and final pathology reported a pT1c( 1,9 cm) invasive ductal carcinoma, SBR II, w DCIS high grade within the mass, L1V1, Ki67 20%, All Negative Margins, ER-ve / PR-ve and Her-2-neu 3+ by IHC, pN0 (0/4 SN), M0 by FDG PET CT Scan criteria. She was offered adjuvant chemotherapy with 6 cycles of TCH + Perjeta.

Do you give adjuvant PMRT since it was a skin/nipple sparing surgery?

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1. No. Negative margins with a good surgery, extensive EIC is not a valid reason for chest wall treatment. Assuming nipple was removed and margins are negative as well. Tiny invasive disease, would not treat. Assume patient getting adjuvant/maintenance Her2 directed therapy.
2. Nipple/skin sparing mastectomies are routine at my institution for anything not obviously within the nipple-areolar complex. Why is pT1cN0 getting TCHP? Regardless, to answer your question, no indication to treat in this situation.
 
Agree with no XRT for either.
 
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