Complex elderly breast case.

[BobbyHeenan]

I have an 83 year old that had a 5 cm VERY far medial left breast mass, eroding into skin and rib/pec muscle. She has a number of comorbidities including CHF with a pacer/defib.

Clinical staging was T3N1 (a few axilla nodes)M0.

She had an excision of the mass (just did a "lumpectomy") and axillary dissection. + margins into the chest wall muscle as you'd expect. Really surgeon didn't think she'd do as well with a mastectomy and family reports surgery was "really hard on her" so no more plans for surgery. She's definitely strong enough to do post op radiation, ECOG is 1. Med onc says no chemo.

Final path staging T3N1 with 3/15 nodes positive, largest 2.1 cm with ECE. + margin on tuomr with dermal invasion but no skin ulceration. +LVSI. Invasive ductal carcinoma, ER/PR +, her 2 (-).

Here's the rub - her pacemaker is right in front of her left axilla. No way to treat this area without moving hte pacer.

I'm thinking maybe just treating her lumpectomy cavity as long as her post op CT I'm getting shows no gross nodes.

Is this crazy?

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[zpiff]

I would move pacemaker. 2.1 cm w/ +ECE is going to recur otherwise. LVI is extensive is also going to make axilla high risk. Would make sure you have good staging.

 

[BobbyHeenan]

I would move pacemaker. 2.1 cm w/ +ECE is going to recur otherwise. LVI is extensive is also going to make axilla high risk. Would make sure you have good staging.

Yes, I'm restaging her.

Right now she's declining an operation to move pacemaker. I am going to personally call the EP cards doc to get an idea of his thoughts here on moving it.

 

[medgator]

Yes, I'm restaging her.

Right now she's declining an operation to move pacemaker. I am going to personally call the EP cards doc to get an idea of his thoughts here on moving it.

Shouldn't be hard to move it i thought, same day surgery outpatient deal i think

 

[BobbyHeenan]

Shouldn't be hard to move it i thought, same day surgery outpatient deal i think

That was my understanding but I've had a bad experience with this before in a patient (all kinds of complications with moving it) That may have been an anomaly though.

. I'm so far removed from EP/pacer/defib things I'm just not well versed here.

 

[communitydoc13]

If they move AICD make sure that that either move far laterally to the other side or place in pelvis (preferred). I have had pacers moved to the medial contra-lateral side where they still impacted my plan.

I'm not sure that your plan is unreasonable if moving AICD not possible. 83 with AICD criteria CHF? Her life expectancy may be less than 5 years independent of breast CA. Without gross disease, I think her risk of axillary recurrence on endocrine therapy in the short term remains low. Z11 outliers who were excluded due to T3 disease, 3 or more nodes positive, ECE, had very low risk of axillary failure with low tangent radiation and no dissection. Her risk of local failure of course is very high and IM may even be first echelon on a patient like this.

 

[taserlaser]

If they move AICD make sure that that either move far laterally to the other side or place in pelvis (preferred). I have had pacers moved to the medial contra-lateral side where they still impacted my plan.

I'm not sure that your plan is unreasonable if moving AICD not possible. 83 with AICD criteria CHF? Her life expectancy may be less than 5 years independent of breast CA. Without gross disease, I think her risk of axillary recurrence on endocrine therapy in the short term remains low. Z11 outliers who were excluded due to T3 disease, 3 or more nodes positive, ECE, had very low risk of axillary failure with low tangent radiation and no dissection. Her risk of local failure of course is very high and IM may even be first echelon on a patient like this.

Never seen a pelvic pacemaker, didn’t even realize that was an option. Keeping that one in my back pocket, thanks.

 

[OTN]

I would push to move the pacer. If not, one could argue that her +SM is more likely to cause problems with morbidity in the future, and as mentioned hormone therapy may be able to control the axilla for awhile. So, you could just target the breast/whatever you get without moving the pacer. Sounds like you could boost the area of +SM without concern for the pacer.

You could always have the pacer moved in the future if she recurred in the axilla/SCV, then tx definitively. I've had success treating SCV recurrence to 70.2 Gy with curative intent.

 

[scarbrtj]

You take an 80+ yo to surgery enough times, even a “simple” pacer repositioning, eventually you’ll put them in the SICU. Her top two areas for recurrence, in order, are systemic and local at the positive margin region. Ergo, the top two interventions you could make are systemic (here likely just anti estrogen therapy) and local RT as you described. I bet her cancer disease process started years ago. She’s 83 and has a pacemaker, so, you know, I’m not an ageist, but I am a realist.

 

[elementaryschooleconomics]

CIEDs: the Penguin to our Batman

If they move AICD make sure that that either move far laterally to the other side or place in pelvis (preferred). I have had pacers moved to the medial contra-lateral side where they still impacted my plan.

Same - moved it to the contralateral side, plan looked fine in Eclipse, pacer was getting torched with scatter on in vivo dosimetry.

 

[BobbyHeenan]

You take an 80+ yo to surgery enough times, even a “simple” pacer repositioning, eventually you’ll put them in the SICU. Her top two areas for recurrence, in order, are systemic and local at the positive margin region. Ergo, the top two interventions you could make are systemic (here likely just anti estrogen therapy) and local RT as you described. I bet her cancer disease process started years ago. She’s 83 and has a pacemaker, so, you know, I’m not an ageist, but I am a realist.

This is my concern too. Family has said every time she gets anesthesia it takes her more and more week(s) to get her strength back.

Right now she's living independently.

Tough case.

I can definitely get 66 Gy into her cavity and most of the breast if need be without bothering her pacer.

I'm going to have her meet with cards to get their eyeball test and re-group.

 

[evilbooyaa]

Would try to get patient/family on board with moving pacemaker, into like R Axilla (far far from field edge).

If she does, then treat comprehensive 3-field. Including IMNs in this very medial tumor with CW invasion where IM very reasonably could be first echelon.

If she adamantly does not want pacemaker removed, discuss increased risk of recurrence, then blast away to just primary disease. I wouldn't necessarily bother with whole breast if this was the case, just APBI-style dosing. Maybe consider taking area of + SM to 35 or 40/5 if doing APBI IMRT like per Livi trial from Italy.

Although the consideration of dermal lymphatic invasion is concerning for spread throughout the breast, so maybe WBI not wrong.

 

[BobbyHeenan]

Update....

Patient is declining a move of the pacemaker to the other side. She has apparently a particular type (?3-wire/biventricular?) where it's a little trickier. EP still offered it but she declined.

CT scans show two internal mammary nodes. No obvious axilla nodes. No distant mets.


I"m planning to treat her cavity and IM nodes. Probably looking at some sort of photon/electron/IMRT combo. Not sure she can do breath hold. I may get some of the rest of the breast but can't treat it all due to pacemaker.

Really tough case. I'll review with my partners but I appreciate the above feedback, all helpful.

 

[evilbooyaa]

Not ideal in terms of purely oncologic management, but some RT likely better than no RT. IMRT of APBI + IMC with SIB to gross IM LNs would be my preference. Sequential boost to gross disease not wrong either. Was thinking say 60/30 with SIB to 66/30 to gross disease and positive margin area

 

[dieABRdie]

Update....

Patient is declining a move of the pacemaker to the other side. She has apparently a particular type (?3-wire/biventricular?) where it's a little trickier. EP still offered it but she declined.

CT scans show two internal mammary nodes. No obvious axilla nodes. No distant mets.


I"m planning to treat her cavity and IM nodes. Probably looking at some sort of photon/electron/IMRT combo. Not sure she can do breath hold. I may get some of the rest of the breast but can't treat it all due to pacemaker.

Really tough case. I'll review with my partners but I appreciate the above feedback, all helpful.

Sounds like a great proton case!

 

[Palex80]

Sounds like a great proton case!

Malfunctions of implantable cardiac devices in patients receiving proton beam therapy: incidence and predictors

Photon therapy has been reported to induce resets of implanted cardiac devices, but the clinical sequelae of treating patients with such devices with proton beam therapy (PBT) are not well known. We reviewed the incidence of device malfunctions among ...

www.ncbi.nlm.nih.gov

Not sure if that's true.

 

[Ray D. Ayshun]

Update....

Patient is declining a move of the pacemaker to the other side. She has apparently a particular type (?3-wire/biventricular?) where it's a little trickier. EP still offered it but she declined.

CT scans show two internal mammary nodes. No obvious axilla nodes. No distant mets.


I"m planning to treat her cavity and IM nodes. Probably looking at some sort of photon/electron/IMRT combo. Not sure she can do breath hold. I may get some of the rest of the breast but can't treat it all due to pacemaker.

Really tough case. I'll review with my partners but I appreciate the above feedback, all helpful.

Thanks for the update. If you're thinking the IM nodes are involved, could they serve as canaries for hormone therapy, and if they respond on imaging, you just observe?

 

[BobbyHeenan]

Thanks for the update. If you're thinking the IM nodes are involved, could they serve as canaries for hormone therapy, and if they respond on imaging, you just observe?

Maybe so, I've thought about that as well. She's immediately post op, so I guess they could be inflammatory but they look real to me.

Wouldn't fault anyone for that move (ie observing) but I think I'm going to treat her.

 

[evilbooyaa]

Thanks for the update. If you're thinking the IM nodes are involved, could they serve as canaries for hormone therapy, and if they respond on imaging, you just observe?

In a neoadjuvant setting, maybe you could consider this (although I don't think anybody would advocate not treating IMNs in the setting of cN+ --> Neoadjuvant therapy --> yrN0 disease), but in a post-mastectomy patient I don't see any reason to not cover the IMC chain with this story. Granted, this case is a cluster all around, but if it's close to post-op target, why leave potential gross disease untreated?

If patient had no cross-sectional imaging prior to surgery one has no idea whether they are real or inflammatory.

 

[Ray D. Ayshun]

In a neoadjuvant setting, maybe you could consider this (although I don't think anybody would advocate not treating IMNs in the setting of cN+ --> Neoadjuvant therapy --> yrN0 disease), but in a post-mastectomy patient I don't see any reason to not cover the IMC chain with this story. Granted, this case is a cluster all around, but if it's close to post-op target, why leave potential gross disease untreated?

If patient had no cross-sectional imaging prior to surgery one has no idea whether they are real or inflammatory.

True about pre-op imaging. I meant observe everything, or treat everything

 

[scarbrtj]

why leave potential gross disease untreated?

Because leaving gross disease untreated works in breast cancer. Arguably, it works better than treating. What is the incidence of untreated (axillary) gross disease in SNB+ early stage patients? (This is why rad oncs "hate" Z0011... potentially untreated gross disease.) What is the incidence of IMN positivity in SNB+ patients, or axillary positive patients, depending on mediality/laterality of tumor? Anywhere from 15-50%? What was the IMN recurrence rate in MA.20 e.g. for patients that didn't get IMNs treated (1 in 1000? Whereas we know way more than 1 in 1000 had IMN involvement?)? What is the incidence of gross disease somewhere else in the breast when 1) we either don't treat the whole breast (ie PBI, which is very standard now) or 2) just forego RT altogether after a lumpectomy for invasive disease in older patients? Not treating "occult" gross disease is VERY common. And doesn't have bad oncological impact... in breast... in a plethora of evidence based situations. Just 'cause you have a CT showing an enlarged IMN node, vs not having that CT, it's "potential" gross disease either way as you state. The anathema of potential gross disease untreated is countenanced because we have so much data that says treating POTENTIAL gross disease doesn't help, or adds as much toxicity as helping (especially e.g. in a very old lady with comorbids/heart problems and a pacer).

 

[evilbooyaa]

Oh come on man, not this **** again, not in this clinical situation.

If CT shows an enlarged lymph node without fatty hilum and isn't in a location that can be easily biopsied (like I have done with suspicious axillary LNs after surgery), why not just treat it??

If one treats this patient but does not treat this patient's IMNs and the patient recurs/progresses in the IMN you have no leg to stand on in the setting of a lawsuit. Whatever mental gymnastics one would like to take to justify partially treating gross disease doesn't make a difference to me.

If one wants to omit radiation and commit this patient to a palliative (in this clinical scenario) situation with hormonal therapy alone, then OK, I guess. But I'm not buying this 'untreated gross disease' mental gymnastics that we're gonna go through.

 

[scarbrtj]

If CT shows an enlarged lymph node without fatty hilum and isn't in a location that can be easily biopsied (like I have done with suspicious axillary LNs after surgery), why not just treat it??

IMN inclusion is not a zero toxicity affair esp in someone who's old with (bad lungs?) and a bad heart. "Very medial" tumor that's 5cm and N+ in a very old lady: what's the likelihood of IMN positivity? 15%? I could be off but that's my first guess. An enlarged node on CT in IMN? What's sensitivity and specificity and PPV for that? I don't know. So I'm still thinking a 15% likelihood even with a "suspicious" CT. Also I can't think of one study where IMN treatment affected IMN relapse rates; they look the same (ie really, really low) with or without treatment. "Comprehensive ENI" has both a tenuous grasp on universal definition (always IMN or not?) and efficacy. And isolated IMN therapeutic attention? VERY tenuous grasp. So I wouldn't treat in THIS case. DVHs w/ IMN coverage always really make me stop and think hard about what I'm trying to accomplish. I say this to stir the pot as much as give any similar thinkers cover lol.

If one treats this patient but does not treat this patient's IMNs and the patient recurs/progresses in the IMN you have no leg to stand on in the setting of a lawsuit.

(A) 83yo lady with bad heart problems dies not from comorbids but from locally advanced breast cancer (that was prob long neglected) that's ER+. (B) Has isolated recurrence in IMNs antedating systemic failure. (C) Family decides to call lawsuit on rad onc who gave treatment (but no tx to IMNs, which have no proven effect on surv) but not the chemo doc who denied treatment with a treatment that has a proven effect on survival.

I'd guess the odds of A times B times C are... 1 in 100,000? Or more? So I'm gonna rate this specious

 

[Palex80]

IMN inclusion is not a zero toxicity affair esp in someone who's old with (bad lungs?) and a bad heart.

Absolutely correct.

"Very medial" tumor that's 5cm and N+ in a very old lady: what's the likelihood of IMN positivity? 15%? I could be off but that's my first guess. An enlarged node on CT in IMN? What's sensitivity and specificity and PPV for that? I don't know. So I'm still thinking a 15% likelihood even with a "suspicious" CT.

I'd say higher. Let's say it's 60%.

Also I can't think of one study where IMN treatment affected IMN relapse rates; they look the same (ie really, really low) with or without treatment.

Indeed. But I also can't think of a study that actually looked into that. And when I say "looked into that", I mean by defining isolared relapse in IMN as an endpoind and actually performing tests (-->CT) to find that out. Since no study actually looked into that, we don't really know.

Given the complex case, I cannot really tell what I would do. I think it's one of those cases, where you have to actually look at the patient and make up your mind. I think both approaches are valid and I am rather leaning towards "don't overtreat, cause this lady will probably be fine off with an aromatase inhibitor and die in a couple of years fdue to one of her other conditions without ever experiencing breast cancer recurrence regardless of the radiation therapy she received".

 

[scarbrtj]

Given the complex case, I cannot really tell what I would do. I think it's one of those cases, where you have to actually look at the patient and make up your mind. I think both approaches are valid and I am rather leaning towards "don't overtreat, cause this lady will probably be fine off with an aromatase inhibitor and die in a couple of years fdue to one of her other conditions without ever experiencing breast cancer recurrence regardless of the radiation therapy she received".

Must be some sort of worldwide healing taking place given you and I significantly agreeing on a breast case lol.

I'd say higher. Let's say it's 60%.

Probably moot but a little high imho. The rubric I have in my mind for IMN+ is 5%/20%/10%/50% for outer qu, ax-/outer qu, ax+/inner qu, ax-/inner qu,ax+. (I guessed 15% in this ax+, outer qu case instead of 20% because she's old.)

Indeed. But I also can't think of a study that actually looked into that. And when I say "looked into that", I mean by defining isolared relapse in IMN as an endpoind and actually performing tests (-->CT) to find that out. Since no study actually looked into that, we don't really know.

I don't know HOW they looked into it, and pardon the somewhat antediluvian data, but:
Selective avoidance of postoperative locoregional radiotherapy in breast cancer seems to be justified...
1/836 isolated IMN recurrences, all without IMN RT.
Long-term follow-up of axillary node-positive breast cancer patients receiving adjuvant systemic therapy alone: patterns of recurrence...
No patients got XRT, anywhere. 140/320 ax+ patients developed isolated LR recurrence, and of the 140 who recurred,
- 60 CW only
- 22 sclav only
- 21 ax only (20/21 had 5 or less nodes dissected)
- 10 multiple sites
- 1 out of 140 had IMN relapse
Frequency, sites of relapse, and outcome of regional node failures following conservative surgery and radiation of early breast cancer...
"The single patient (out of 990 patients) who developed an internal mammary node recurrence had an initial T1 outer quadrant primary with seven negative axillary nodes. There have been no internal mammary node recurrences either in the 455 patients with an inner quadrant or central primary tumor (positive or negative axillary nodes) or an outer quadrant primary with histologically positive axillary nodes who received no treatment to the internal mammary nodes, or in the 154 such patients who received treatment to this region."
Ten-year survival results of a randomized trial of irradiation of internal mammary nodes after mastectomy...
Zero(?) reported IMN relapses in 1334 patients (and distant relapses outnumbered LR relapses 10-to-1...) and no IMN-RT benefits, OS or otherwise.

Using just the above numbers it's like ~1/2000 patients with no RT who got IMN relapse ... and ~1/2000 patients who got IMN RT and had an IMN relapse. This is not a real fruitful therapeutic site.

However, there is that provocative DBCG retrospective analysis showing a 4% OS improvement with IMN-RT in ~3000 patients.
EDIT... Of course I'd be remiss not to point out something like the MA.20 which had ~0% risk of IMN recurrence in ~1000 patients with IMN-RT vs ~1000 patients without IMN-RT.

 

[evilbooyaa]

@scarbrtj
Difference between a IMN recurrence (not able to be palpated) vs a chest wall, axillary, or supraclavicular recurrence. Nobody is doing surveillance on breast cancer patients with q3 month chest CTs. Very very few patients will have a clinically apparent IMN relapse (maybe direct invasion into sternum causing pain, prompting CT scan?), but that does not necessarily mean that they are not recurring there.

Absence of evidence is not the evidence of absence.

Again, the clinical utility across all patients, most of which probably didn't have visible adenopathy in IMN, is questionable, I agree with you on that.

However, for this patient, with a medial tumor, and axillary LN+, with post-operative 3-dimensional imaging showing suspicious adenopathy in IMC (with likely no 3-dimensional imaging pre-operatively - if she did and these lymph nodes were not present, then could buy them as inflammatory) I would estimate the risk of her having, the risk is higher.

The table you cited in your own post puts the risk of this axilla positive patient with an inner quadrant tumor to be 44-65%! And that's in patients diagnosed by surgical removal, so catching microscopic amounts of disease (at least as per the Handley paper from 1975, reference 13). What do you think this patient's percentage is with evidence of adenopathy in IMNs on CT scan?

 

[scarbrtj]

@scarbrtj
Difference between a IMN recurrence (not able to be palpated) vs a chest wall, axillary, or supraclavicular recurrence. Nobody is doing surveillance on breast cancer patients with q3 month chest CTs. Very very few patients will have a clinically apparent IMN relapse (maybe direct invasion into sternum causing pain, prompting CT scan?), but that does not necessarily mean that they are not recurring there.

Absence of evidence is not the evidence of absence.

Again, the clinical utility across all patients, most of which probably didn't have visible adenopathy in IMN, is questionable, I agree with you on that.

However, for this patient, with a medial tumor, and axillary LN+, with post-operative 3-dimensional imaging showing suspicious adenopathy in IMC (with likely no 3-dimensional imaging pre-operatively - if she did and these lymph nodes were not present, then could buy them as inflammatory) I would estimate the risk of her having, the risk is higher.

The table you cited in your own post puts the risk of this axilla positive patient with an inner quadrant tumor to be 44-65%! And that's in patients diagnosed by surgical removal, so catching microscopic amounts of disease (at least as per the Handley paper from 1975, reference 13). What do you think this patient's percentage is with evidence of adenopathy in IMNs on CT scan?

View attachment 322778

The OP post was so long ago I was misremembering it as “very far lateral” or misreading it as that. You guys were right... her risk is 50 plus percent w/ a medial tumor. Even before the CT. But regardless of the risk of IMN occult positivity, one must dose here based on treating microscopic disease or gross disease (if you’re going to dose the IMNs at all). If you think the node is real it needs 66 Gy, or more. I wouldn’t be enthused to give that high of dose without biopsy confirmation, even with a high risk and the CT suspicion. Giving an ENI dose, even for medial tumor/axillary positive patients (who have high IMN risk) doesn’t seem to affect outcomes (much). To me, treat the IMNs to high definitive dose here (a believer’s approach) or not at all (the non believer’s approach). Neither’s wrong. If the IMNs were proven positive, I’d definitely treat them. As stands, I wouldn’t. But I can see why one would.