Breast is the worstest of the worstest: Late recurrence and re-irradiation.

[Palex80]

Invasive lobular breast cancer on the left side pT1c pN0 (sn), received BCS und adjuvant RT to the breast (50 Gy to the breast + 10 Gy boost) in 2002, she was in der 40s back then. ER+ PR+ Her2-

She remained in remission for 20 years, underwent adjuvant endocrine therapy for 5 years.

Now, in her 60s, she presents with a large recurrent tumor (8cm) in the left breast and one possible axillary node. PET-CT negative for futher disease. Biopsy shows the exact same biology as 20 years ago.

Mastectomy and ALND is performed. pT3 pN1 (2/4) R0. Macrometastatic nodes, no ECE, some L1 in the ALND-sample however. I have no idea why the pathologists only found 4 nodes in total. The ALND specimen is adequately big, this was not a TAS (8 x 4 x 2 cm). No reconstruction planned.

I am going to treat chest wall and lymphatics (IM and the supraclavicular fossa.), my only question is:
Do I treat the axillary nodes too?

I would have not treated it, if there were a few more negative nodes, but 2/4 + L1 worries me.
On the other hand, she has had dose there from the breast tangent 20 years ago and combined with the two surgeries she has had in the axilla, her risk for complications (edema and possibly plexopathy) will be quite high.

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[RadOncDoc21]

Invasive lobular breast cancer on the left side pT1c pN0 (sn), received BCS und adjuvant RT to the breast (50 Gy to the breast + 10 Gy boost) in 2002, she was in der 40s back then. ER+ PR+ Her2-

She remained in remission for 20 years, underwent adjuvant endocrine therapy for 5 years.

Now, in her 60s, she presents with a large recurrent tumor (8cm) in the left breast and one possible axillary node. PET-CT negative for futher disease. Biopsy shows the exact same biology as 20 years ago.

Mastectomy and ALND is performed. pT3 pN1 (2/4) R0. Macrometastatic nodes, no ECE, some L1 in the ALND-sample however. I have no idea why the pathologists only found 4 nodes in total. The ALND specimen is adequately big, this was not a TAS (8 x 4 x 2 cm). No reconstruction planned.

I am going to treat chest wall and lymphatics (IM and the supraclavicular fossa.), my only question is:
Do I treat the axillary nodes too?

I would have not treated it, if there were a few more negative nodes, but 2/4 + L1 worries me.
On the other hand, she has had dose there from the breast tangent 20 years ago and combined with the two surgeries she has had in the axilla, her risk for complications (edema and possibly plexopathy) will be quite high.

I feel like I’m seeing a lot more of these kinds of cases. She’s still young so I think an aggressive approach is definitely what I would consider and I think you should treat the axilla. Now of course the dose and fractionation to give, I will leave this to the “experts.”

I think I would do something like BID or give a very wimpy dose of like 45 Gy in 1.8 Gy/fx, consent the hell out of her and pray!

 

[TheWallnerus]

Her risk from re-RT complications is terribly high. Throw in the left sided aspect and (potential, given all the RT) heart issues too for good measure. I find it surprising she got sentinel node only axillary “therapy” in 2002, in Europe. This was my first thought as why only 4 axillary nodes found now… how big is the scar in her armpit?

Tell us what concoction medical oncology is planning. It will certainly be a different systemic therapy now than what she got 20 years ago (which obviously was just hormone therapy). I think this significantly weighs on my potential RT thought processes.

Permission to speak freely? I am vehemently opposed to IMN RT here. I am very vociferously opposed to any axillary RT. Can we please stop trying to therapize axillae, especially in a case like this.

 

[RadOncDoc21]

Her risk from re-RT complications is terribly high. Throw in the left sided aspect and (potential, given all the RT) heart issues too for good measure. I find it surprising she got sentinel node only axillary “therapy” in 2002, in Europe. This was my first thought as why only 4 axillary nodes found now… how big is the scar in her armpit?

Tell us what concoction medical oncology is planning. It will certainly be a different systemic therapy now than what she got 20 years ago (which obviously was just hormone therapy). I think this significantly weighs on my potential RT thought processes.

Permission to speak freely? I am vehemently opposed to IMN RT here. I am very vociferously opposed to any axillary RT. Can we please stop trying to therapize axillae, especially in a case like this.

I get the concerns, but what if there is another recurrence in the axilla? Would the surgeon still want to operate and what would we give to gross disease vs post-op RT or do we leave it alone again, knowing that at some point we may need to pull the trigger in the axilla?

I think another disease recurrence is a greater risk in my opinion but admittedly I’m in the breast is the worst camp!

 

[TheWallnerus]

I get the concerns, but what if there is another recurrence in the axilla? Would the surgeon still want to operate and what would we give to gross disease vs post-op RT or do we leave it alone again, knowing that at some point we may need to pull the trigger in the axilla?

I think another disease recurrence is a greater risk in my opinion but admittedly I’m in the breast is the worst camp!

I don’t know that it was left alone in the first place. Certain parts of Europe really find it hard to leave the axilla alone, think Z0011 is a curse word, etc. (EDIT: still want to know planned systemic therapy now… it treats axilla.)

Palex… just to clarify, this was an undissected and completely unirradiated axilla?

Also how was the recurrence found. By specialist in 20 year followup? By annual mammogram? By the patient suddenly noticing a T3 lump?

 

[Palex80]

Her risk from re-RT complications is terribly high. Throw in the left sided aspect and (potential, given all the RT) heart issues too for good measure. I find it surprising she got sentinel node only axillary “therapy” in 2002, in Europe. This was my first thought as why only 4 axillary nodes found now… how big is the scar in her armpit?

I haven't see her yet, but yes, she only had a sentinel procedure back in 2004. Her scar is going to be big now, she had an ALND this year.

Tell us what concoction medical oncology is planning. It will certainly be a different systemic therapy now than what she got 20 years ago (which obviously was just hormone therapy). I think this significantly weighs on my potential RT thought processes.

Oh, sorry, forgot about that. They are going to give her Palbociclib with an aromatase inhibitor. No chemo. She only had tamoxifen with an LHRH 20 years ago, since she was premenopausal back then and low risk.

Permission to speak freely? I am vehemently opposed to IMN RT here. I am very vociferously opposed to any axillary RT. Can we please stop trying to therapize axillae, especially in a case like this.

I knew this was coming. The tumor did spread into the inner quadrants of the breast, which is why I am treating IM.

Palex… just to clarify, this was an undissected and completely unirradiated axilla?

2002 she had a BCS+sentinel procedure. Postoperative radiation was only breast, no lymphatics, normal tangent. Some incidental dose in the axilla warranted, I ordered the films.

2022 she had a mastectomy+ALND

Also how was the recurrence found. By specialist in 20 year followup? By annual mammogram? By the patient suddenly noticing a T3 lump?

The T3 lesion interestingly went undetected despite yearly mammograms, the patient noticed the lump this spring.
I feel that this was a slowly growing recurrent tumor. Ki67 is also low, around 10%, and the PET-CT did not show a high SUV.

 

[TheWallnerus]

I haven't see her yet, but yes, she only had a sentinel procedure back in 2004. Her scar is going to be big now, she had an ALND this year.

Oh, sorry, forgot about that. They are going to give her Palbociclib with an aromatase inhibitor. No chemo. She only had tamoxifen with an LHRH 20 years ago, since she was premenopausal back then and low risk.

I knew this was coming. The tumor did spread into the inner quadrants of the breast, which is why I am treating IM.


2002 she had a BCS+sentinel procedure. Postoperative radiation was only breast, no lymphatics, normal tangent. Some incidental dose in the axilla warranted, I ordered the films.

2022 she had a mastectomy+ALND


The T3 lesion interestingly went undetected despite yearly mammograms, the patient noticed the lump this spring.
I feel that this was a slowly growing recurrent tumor. Ki67 is also low, around 10%, and the PET-CT did not show a high SUV.

Is it normal not to add cytotoxic chemo now for T3 node positive tumors? That’s interesting.

IMN RT will do zero to affect her long term outcome. Certainly will not affect survival. Much the same story for axillary RT too, except you will definitely have a very good chance of affecting her QoL. I would bet my SDN membership card on her not having an isolated axillary recurrence if you don’t irradiate (the axilla).

 

[Palex80]

Is it normal not to add cytotoxic chemo now for T3 node positive tumors? That’s interesting.

I feel this has to do with the fact that this a recurrence and recurrences are treated differently than primary tumors (or let's just say "one cannot simply extrapolate the evidence from the primary setting in the recurrence setting").
There was one randomized trial conducted with this question and it was positive mostly for tumors with negative hormone receptors.

Chemotherapy for Isolated Locoregional Recurrence of Breast Cancer: The CALOR Randomised Trial

Patients with isolated locoregional recurrences (ILRR) of breast cancer have a high risk of distant metastasis and death from breast cancer. We investigated adjuvant chemotherapy for such patients in a randomised clinical trial.The CALOR trial ( ) accrued ...

www.ncbi.nlm.nih.gov

I believe this is why it was not recommended, since she still has the same biology as before.

IMN RT will do zero to affect her long term outcome.

It will certainly have an impact on my long-term "slepp well at night" outcome.

Certainly will not affect survival.

I am not a medical oncologist.

Much the same story for axillary RT too, except you will definitely have a very good chance of affecting her QoL.

That is true, and I am struggling here.

I would bet my SDN membership card on her not having an isolated axillary recurrence if you don’t irradiate (the axilla).

I am not going to accept that bet. I am leaning against irradiating the axilla. I am going to call the pathologists and ask them to look further for more nodes in that ALND specimen.

 

[TheWallnerus]

one cannot simply extrapolate the evidence from the primary setting in the recurrence setting

So why try to do this with the RT approaches, fields, thinking in this case

Now tell us what doses you’re going to use.

EDIT: I would just expound one bit more. Seems med onc is low balling it here. Which is interesting because she has like a 40-50% chance of having breast cancer cells in her marrow. And yeah, even maybe a 50% chance of having positive IMNs right now. I am mentioning these things because they are cognitively dissonant and highly counterintuitive to our thought processes. But for med onc to lowball it and rad onc to throw the kitchen sink seems REALLY counterintuitive. Even though a local recurrence is the problem before us.

 

[Palex80]

So why try to do this with the RT approaches, fields, thinking in this case

We are not medical oncologists.

Now tell us what doses you’re going to use.

I am going to give 50.4 Gy to the chest wall and 45 Gy to the lymphatics. 1.8 Gy per day - BOOMER-Style.

 

[TheWallnerus]

We are not medical oncologists.

I am going to give 50.4 Gy to the chest wall and 45 Gy to the lymphatics. 1.8 Gy per day - BOOMER-Style.

That’s the right answer for dose imho. No bolus. Please don’t show me the heart or left lung DVH for this plan though. It will just embitter me.

 

[RadOncDoc21]

Boomer style is tried but true… No shame in the game!

 

[RickyScott]

I have used pulsed dose. Cumulative doses greater than 100gy to brachial plexus.

 

[RickyScott]

I have used pulsed dose. Cumulative doses greater than 100gy to brachial plexus

Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy for breast cancer recurrence in the previously irradiated chest wall, axilla, or supraclavicular region - PubMed

With a median follow-up of 18 months, PRDR appears to be an effective method to reirradiate large volumes of previously irradiated tissue in selected patients with locoregional chest wall, axilla, and supraclavicular recurrences.

pubmed.ncbi.nlm.nih.gov

 

[Palex80]

I have used pulsed dose. Cumulative doses greater than 100gy to brachial plexus

Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy for breast cancer recurrence in the previously irradiated chest wall, axilla, or supraclavicular region - PubMed

With a median follow-up of 18 months, PRDR appears to be an effective method to reirradiate large volumes of previously irradiated tissue in selected patients with locoregional chest wall, axilla, and supraclavicular recurrences.

pubmed.ncbi.nlm.nih.gov

 

[Palex80]

I saw the patient today, she already has a bit of lymphedema and is concerned about toxicity. I am omitting axillary RT, will treat chest wall, internal mammary nodes, supraclavicular fossa (and try to match the PTV-borders to the 70% isodose of the previous breast-plan in the cranial parts of the axilla)

 

[evilbooyaa]

Invasive lobular breast cancer on the left side pT1c pN0 (sn), received BCS und adjuvant RT to the breast (50 Gy to the breast + 10 Gy boost) in 2002, she was in der 40s back then. ER+ PR+ Her2-

She remained in remission for 20 years, underwent adjuvant endocrine therapy for 5 years.

Now, in her 60s, she presents with a large recurrent tumor (8cm) in the left breast and one possible axillary node. PET-CT negative for futher disease. Biopsy shows the exact same biology as 20 years ago.

Mastectomy and ALND is performed. pT3 pN1 (2/4) R0. Macrometastatic nodes, no ECE, some L1 in the ALND-sample however. I have no idea why the pathologists only found 4 nodes in total. The ALND specimen is adequately big, this was not a TAS (8 x 4 x 2 cm). No reconstruction planned.

I am going to treat chest wall and lymphatics (IM and the supraclavicular fossa.), my only question is:
Do I treat the axillary nodes too?

I would have not treated it, if there were a few more negative nodes, but 2/4 + L1 worries me.
On the other hand, she has had dose there from the breast tangent 20 years ago and combined with the two surgeries she has had in the axilla, her risk for complications (edema and possibly plexopathy) will be quite high.

Having read only the OP:

20 years later I'm going to call this a new primary, not recurrent disease, despite the same biology.

Plexopathy not going to be an issue with tangents alone treatment unless perhaps if it was high tangents (unlikely based on initial staging).

What is L1?

I would not treat dissected axilla - part of the axilla has already received RT and lymphedema risk will be very high with incidental RT dose from tangents + purposeful reirradiation of the axilla. Would consider IMRT to purposefuly spare the dissected axilla rather than just accepting what is covered in traditional tangents + SCV field.

Covering IMN for recurrent T3 not unreasonable. Agree with covering SCV (no re-RT here).

Reading the rest of the thread:

No benefit of chemotherapy in this scenario as per CALOR trial with the caveat that I am not aware of the tumor sizes on that trial, and 8cm recurrence seems pretty large. Therefore, something that hedges between AC-->T and no systemic therapy seems to make sense here. I think CDKi + AI pretty reasonable.

I presume patient has undergone 3-dimensional imaging to look for metastatic disease at some point? I'm surprised with 8cm recurrence (despite being ER/PR+) there was no neoadjuvant therapy. Not wrong, just variation in practice I think compared to what I'd see locally. Maybe they thought it was recurrent T3N0.

Heart will be an issue on sum plan but it's re-RT. Lung DVH will be fine as majority of the tangential lung dose has already gotten the 20Gy (what is dead may never die) although will depend on anatomy to make sure the SCV field addition meets constraints on a sum plan.

45Gy in 1.8s for re-RT likely reasonable, could consider the BID regimena s well and treat the SCV (not re-RT) how MDACC does for their inflammatory cases.

 

[Palex80]

What is L1?

LVSI

I presume patient has undergone 3-dimensional imaging to look for metastatic disease at some point?

Yes, PET-CT prior to mastectomy + ALND

 

[sirspamalot]

 

[evilbooyaa]

LVSI

L1 is LVSI?

Europeans, man... I don't even...

Anyways, no cares are given about LVSI when the patient has disease in the lymph nodes

 

[Palex80]

L1 is LVSI?

Europeans, man... I don't even...

L1: Lymphangiosis
V1: Haemangiosis

Anyways, no cares are given about LVSI when the patient has disease in the lymph nodes

It depends... The LVSI was seen in the axillary tissue, around the nodes, although there was no ECE. So one could argue that "more" than just the two nodes in the axilla were affected. But, I do see your point.

 

[RickyScott]

L1 is LVSI?

Europeans, man... I don't even...

Anyways, no cares are given about LVSI when the patient has disease in the lymph nodes

So I had this exact question in residency many years ago and was told Lvi is still an aggressive feature even in setting of +nodes. Never looked into it.

 

[FindMeOnTheLinks]

This seems like it would have been a good case for neoadjuvant systemic therapy given the locally advanced disease….8cm is a big tumor. would love to know the degree of pathologic response, especially in the nodes to help inform extent of treatment. If good response, would feel a lot more comfortable omitting regional nodal coverage

 

[Palex80]

This seems like it would have been a good case for neoadjuvant systemic therapy given the locally advanced disease….8cm is a big tumor. would love to know the degree of pathologic response, especially in the nodes to help inform extent of treatment. If good response, would feel a lot more comfortable omitting regional nodal coverage

I think the argument was, that Ki67 was low and thus response to chemo would not have been great.

 

[TheWallnerus]

I think the argument was, that Ki67 was low and thus response to chemo would not have been great.

A Ki67 result held the patient from getting chemo here. A T3 node positive patient with LVI on path. With recurrent disease. I just don’t think I would ever see that from the med oncs with which I work, but maybe I’m wrong.

The presence of just 2 positive lymph nodes would have held the patient from getting any radiation in the not so distant past; would have been the tumor board recommendation ~12y ago. Re-interpretation* of a single Danish trial that started accruing 40y ago changed rad onc thinking ‘bout that. I guess 9-10y ago the recommendation became PMRT. Then 7y ago, PMRT plus all the nodes. I don’t think a single patient, of thousands of patients, in any of these trials that spurred standard of care changes in rad onc received Herceptin.

I wonder if breast cancer treatments outside of radiation (#sarcasm) have changed enough in the last 40 years to make us not always fall back on an essentially 40 year old approach to “strongly consider” (what the NCCN would say to do here) PMRT for one or two lymph node positive post-mastectomy patients. I won’t lie… I had to Google palbociclib.



*EBCTCG

 

[Palex80]

A Ki67 result held the patient from getting chemo here.

Well, yes... Add to that the highly positive ER/PR and then negative Her2new results.

 

[TheWallnerus]

Well, yes... Add to that the highly positive ER/PR and then negative Her2new results.

Just thinking we (by we, I mean the med oncs) had much more “precision oncology” these days than a Ki67 score. Be that as it may I think even the clunky non precision calculators that account for Ki67 would predict a chemotherapy survival benefit here.

 

[Palex80]

Just thinking we (by we, I mean the med oncs) had much more “precision oncology” these days than a Ki67 score. Be that as it may I think even the clunky non precision calculators that account for Ki67 would predict a chemotherapy survival benefit here.

I assume hey didn't order a genetic test, like OncotypeDx, because this was a recurrence (or at least that's how they saw it and not a second primary), thus the validity of a such test result is limited in the recurrence setting.

 

[RadOncDoc21]

A Ki67 result held the patient from getting chemo here. A T3 node positive patient with LVI on path. With recurrent disease. I just don’t think I would ever see that from the med oncs with which I work, but maybe I’m wrong.

The presence of just 2 positive lymph nodes would have held the patient from getting any radiation in the not so distant past; would have been the tumor board recommendation ~12y ago. Re-interpretation* of a single Danish trial that started accruing 40y ago changed rad onc thinking ‘bout that. I guess 9-10y ago the recommendation became PMRT. Then 7y ago, PMRT plus all the nodes. I don’t think a single patient, of thousands of patients, in any of these trials that spurred standard of care changes in rad onc received Herceptin.

I wonder if breast cancer treatments outside of radiation (#sarcasm) have changed enough in the last 40 years to make us not always fall back on an essentially 40 year old approach to “strongly consider” (what the NCCN would say to do here) PMRT for one or two lymph node positive post-mastectomy patients. I won’t lie… I had to Google palbociclib.



*EBCTCG

Breast is the worstest