cT3N0M0 breast case - what to do with axilla?

[BobbyHeenan]

49 year (possibly pre-menopausal - had been on oral contraception....physiologically looks very young...i don't have her hormone labs) old with a cT3N0M0 breast high grade IDC. ER/PR+, Her 2 (-).
Up front had one lymph node in axilla that in retrospect our best breast radiologist says looks normal to her....this was biopsied though and this lymph node was negative.

She then went forward with mastectomy.
One 6.5 cm tumor, another tumor in a different quadrant 1 cm. LVSI was "suspicious." Margins negative (6mm away). Unfortunately the tracer/dye didn't map to the axilla and path couldn't find any nodes in the mastectomy specimen.

So we're mpT3Nx.

I'm planning on treating her chest wall and regional nodes.

Does she need to go back for dissection?

We were thinking at breast tumor board to image her chest with a CT scan and if no nodes more concerning than just a post op inflammatory type node then omit axilla dissection and just cover her axilla with her post mastectomy radiation.

Would love to hear other thoughts on this though. I think we all agreed no survival advantage to her dissection. Med onc says "very likely" to give her chemo unless oncotype is super low ...so I'm not sure that it's going to change her management . I was leaning toward post mastectomy anyway, so if she has a negative dissection I'm not sure that fully flips me from Yes XRT to no XRT....

But I'm open to hearing thoughts.

Thanks.

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[RickyScott]

Agree with no further dissection and covering axilla.

 

[TheWallnerus]

The dissection wouldn't be survival improving.
RNI would not be survival improving.
Chemo (if oncotype suggests) and tamoxifen will be survival improving.
Exercise regimens will be survival improving.
She is 49. What is her "reconstruction status."
I would completely demur all RT if reconstructed.

 

[BobbyHeenan]

The dissection wouldn't be survival improving.
RNI would not be survival improving.
Chemo (if oncotype suggests) and tamoxifen will be survival improving.
Exercise regimens will be survival improving.
She is 49. What is her "reconstruction status."
I would completely demur all RT if reconstructed.

Yeah I get what you're saying.

She's s/p bilateral mastectomies. No expanders placed. I can't recall if she may ever go on to have some sort of autologous reconstruction but no plastics has been involved thus far that I'm aware of.

 

[Palex80]

I'd treat. Probably premenopausal status and pT3, that's enough reason. And I'd cover the axilla too.

 

[evilbooyaa]

I think one could pontificate whether omission of RT would be reasonable in a cT3N0 s/p upfront surgery with nodal dissection (which would be this patient if she went back for ALND and it was negative). But, would not be a fan of letting this patient escape BOTH ALND and RNI.

I would favor, in the case as presented, omission of ALND and treat CW + RNI. If medial tumor, I would personally cover IMCs. This is an extrpaolation of SLNB studies (The purists may say inappropriate extrapolation given inclusion criteria of AMAROS/Z11), but given a general push to avoid ALND as much as possible in breast Ca patients, I wouldn't hate it.

This is an excellent case to do this on, as she hasn't had recon. Lots of small changes to the case make this a much more problematic one, IMO.

 

[BobbyHeenan]

Thanks all. Tough case and the wheels are spinning in your heads where mine was going too.