difficult breast case

[Cancerdancer]

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seeing a tough consult, interested in anyone's thoughts.

60ish woman, treated w/ lump & ax dissection mid 1990s (when she was mid-40's) for T1 ER+ PR+ IDC R breast, w/ 1/12 nodes positive. Got tangents + boost at OSH. Stopped endocrine therapy shortly after starting.

Now found on mammo to have recurrent R IDC near original tumor bed. Undergoes mastectomy w/ DIEP reconstruction. Recurrent primary 2.5 cm, ER+ PR+, Gr 2, no LVI, and (-) margins by 2.5 cm. SLN maps to IM (hot, not blue). Surgeon re-dissects axilla, gets 2 LNs (-). Plastic surgeon resects 1 hot LN from the IM region as he's harvesting the IM vessels to anastamose DIEP, final path shows 6 mm focus of disease, no ECE.

So, recurrent vs new primary pT2 pN1b. Haven't seen her yet, but surgeon said her tissue was very woody from previous RT.

Would it be crazy to treat an electron field to the IM chain only? vs not treat vs comprehensive...thanks!

 

[Brim]

That's a crazy / tough case.

Has she had restaging scans yet, just to be sure she's not got distant mets?

It's a weak case for needing comprehensive post-mastectomy RT. It's reasonable to consider RT to the IMN; however, the evidence for any benefit from treatment is weak. Hopefully, the toxicity for retreatment will be mitigated by the time of >10 yrs since prior RT and the fact that it's right-sided.

Certainly any benefit of RT is going to be far less than the benefit of systemic therapy. You could thus make an equally valid argument not to treat.

It's a tough call. I'd probably treat, extrapolating from retreatment of locoregionally recurrent cancers of the breast, with acceptable toxicity. It's an excellent case for discussion in Chartrounds, btw.

 

[medgator]

Some multi-institutional data on the feasibility/outcomes of repeat breast/CW rt, fyi

http://www.ncbi.nlm.nih.gov/pubmed/17869019

I'd probably treat as well, and go for comprehensive, rather than just targeting IMs

 

[ShirleyT]

Wow, that is a very tough case. I second the idea of chartrounds.com presentation, i think it would be very helpful and interesting. I would definitely get the restaging scans to rule out DM but would lean towards comprehensively treating, the only thing making me nervous is the fact that the surgeon said tissues were woody from prior RT. can you get old records to see the doses and see how "hot" the old plan was? maybe if you treat go at 1.8 Gy per fraction to take it easier on the tissues.

 

[Pointless]

You could also consider BID fractionation if you are going to re-treat, but you are definitely in no-man's land here. Good luck, tough case.

 

[Winged Scapula]

Surgeon barging in here...

RE: "woody tissue"

Ask/check how much of that was excised during mastectomy. If this was a skin sparing mastectomy, then you might find a significant amount of radiated tissue outside the DIEP flap, perhaps compromising your treatment decisions.

If the patient was being reduced in size or had a significant amount of redundant skin, with a large mastectomy resection, much of the radiated tissue may have been removed prior to reconstruction.

 

[deleted4401]

Ugh.

If this was de novo case and not recurrent, everyone would treat, right? Comprehensive - CW/SCV/level III, and IMN I-V?

I'd treat comprehensive. She's a patient that is highly salvageable - long interval since original primary, ER+, stage II at dx, Counsel for potential poor cosmetic outcome, wound healing, skin necrosis. Chemo first? I think so, since these women typically met out and CALOR trial showed a SS survival benefit (subset showed more benefit for ER-, ER+ positive patients don't seem to have as much benefit, but need longer follow-up). http://cancerres.aacrjournals.org/cgi/content/meeting_abstract/72/24_MeetingAbstracts/S3-2
But, our medoncs are reluctant about chemo for recurrent cases, especially if receptor +.

Curious what CR will say. Provide an update!
S