fields for local bc recurrence in axilla

[Bunsen Honeydew]

---

Members do not see this ad.

Can anyone point me to literature on defining treatment fields for LR bc when patient had 3 field initially. I have pt with recurrence in axilla only approx 2-3 yrs out, initially treated to chest wall, SC, axilla s/p u/l mastectomy with axillary LN+ (don't know # offhand.) So recurrence is only in axilla -- we plan to retreat only that area (not chest or supraclav), but i'm looking for supportive literature and having tough time. thanks!

 

[Gfunk6]

This is a pretty unusual case. A brief review of Pubmed did not yield anything useful, but perhaps our more senior and knowledgeable users could contribute?

I guess a couple of important questions would be:

1. What was her initial (and current, if known) HR status?
2. If ER/PR+ did she receive a SERM or AI the first time?
3. Did she receive adjuvant chemo the first time?

Given her nodal failure after both an axillary LND and 3-field XRT, distant failure is her real problem. Therefore, I'm not certain what value additional XRT will add. Personally, I would consider removing a few more nodes surgically and begin salvage chemo.

Can anyone point me to literature on defining treatment fields for LR bc when patient had 3 field initially. I have pt with recurrence in axilla only approx 2-3 yrs out, initially treated to chest wall, SC, axilla s/p u/l mastectomy with axillary LN+ (don't know # offhand.) So recurrence is only in axilla -- we plan to retreat only that area (not chest or supraclav), but i'm looking for supportive literature and having tough time. thanks!

 

[Palex80]

I presume you gave something like 50/2 during her first treatment to the axilla.
This dose did not manage to avoid a recurrence, meaning that you probably have aggressive disease in your hands.

I don't think you have the ability to give something as aggressive as 50/2 after a rather short period, without facing major risks of late treatment sequlae. Bearing in mind that you are retrating the axilla and the patient has already undergone twice axillary resection and one radiotherapy, it could very well be that you are looking at quite high rates of axillary lymphedema >°I and potential nerve damage by retreating her.

I wouldn't treat if I were you, but that's your call. Too much risk for too little benefit IMHO.

Now if I really wanted to treat:
I wouldn't do more than 45/1.8 tops and would probably like to do some hyperfractionation (for example 44/1.1bid).

 

[Brim]

My biggest concern with reirradiating the axilla is the risk of brachial plexopathy.

There is scant data on reirradiation of the breast or chest wall for a locoregional recurrence. I've sent a patient or two for CW reirradiation with concurrent hyperthermia, with good results, but this treatment isn't widely available.

However, I don't know of any publications reporting reirradiation of the axilla.

The standard of care treatment for an isolated axillary recurrence after BCS+RT is surgical excision. I would not give RT. If the patient cannot under an R0 resection, then chemotherapy / hormonal therapy can be considered.

Good luck with your patient, and keep us posted.

 

[Cancerdancer]

Readers of this thread might find this article on PRDR for reirradiation of locoregionally recurrent breast CA of interest, though unlikely to help the OP given limited availability.

http://www.ncbi.nlm.nih.gov/pubmed/18389365

Of note, patients were a mean of 58 months out from previous XRT, and received a median of 54 Gy for re-XRT but:

"There has been no evidence of brachial plexopathy in any patient despite targeting the axilla and/or supraclavicular area in 15 of the 17 patients"

Granted, only 18 months of median f/u, so take it with a big grain of salt...

 

[Gfunk6]

Readers of this thread might find this article on PRDR for reirradiation of locoregionally recurrent breast CA of interest, though unlikely to help the OP given limited availability.

Thanks for sharing this very interesting study and even more interesting technique. How do you administer PRDR RT? HDR catheters, external beam, or something else?

 

[Cancerdancer]

How do you administer PRDR RT? HDR catheters, external beam, or something else?

It's done via external beam...can really be done in most centers. Not sure if I'm really a believer, but it has its proponents. Takes up a lot of LINAC time (30 mins for 2 Gy fraction), if that's a concern...

"Each daily fraction was delivered using 0.2-Gy pulses separated by 3-min intervals, creating an apparent dose rate of 0.0667 Gy/min. The dose rate of the linear accelerator was reduced to 1 Gy/min during each pulse of 0.2 Gy"

Not to hijack the thread (or make claims about PRDR), but Gfunk given your CNS interest you might be interested in the PRDR data for recurrent GBM, same senior author...
PMID: 20472350

 

[Gfunk6]

Not to hijack the thread (or make claims about PRDR), but Gfunk given your CNS interest you might be interested in the PRDR data for recurrent GBM, same senior author...
PMID: 20472350

Very interesting. For re-irradiation of recurrent GBMs we often go the hypofractionated route (3.5 Gy x 10) with stereotactic guidance, based on one of our junior faculty's publications (PMID: 20479391).

We also have some older data showing excellent results in recurrent GBM using LDR brachy +/- hyperthermia in a Phase III trial (PMID: 9457811). Unfortunately, this approach was ultimately dropped due to a lack of enthusiasm from our Neurosurgery chairman in favor of alternative approaches. However, it seems PRDR might be a way for folks without LDR expertise to still use a low-dose rate to obtain good results.

 

[Palex80]

Very interesting. For re-irradiation of recurrent GBMs we often go the hypofractionated route (3.5 Gy x 10) with stereotactic guidance, based on one of our junior faculty's publications (PMID: 20479391).

We also have some older data showing excellent results in recurrent GBM using LDR brachy +/- hyperthermia in a Phase III trial (PMID: 9457811). Unfortunately, this approach was ultimately dropped due to a lack of enthusiasm from our Neurosurgery chairman in favor of alternative approaches. However, it seems PRDR might be a way for folks without LDR expertise to still use a low-dose rate to obtain good results.

Patients with recurrent gliomas usually have a miserable prognosis and we often treat them after they have failed under Temozolomide (+/- Bevacizumab). We also go for the stereotactic approach. 10 x 3,5 Gy is our standard too, we sometimes give 6 x 5 Gy too (especially when the PTV is small). I don't think you are going to gain a lot form PRDR in recurrent glioma. Long term toxicity is not much of an issue there, most patients never survive long enough to experience any. And lying 1 hour under a mask is not very comfortable (provided you want to give something around 3,5 Gy).