Is PMRT needed for this patient?

[Kroll2013]

59 yo female patient, that presented with multifocal right breast lesions in the upper-lower outer quadrants: T1 26.5*21 mm - T2 23*19mm cN0 on the initial MRI.
staging Pet: N0 M0
she underwent neoadjuvant chemotherapy.
MRI showed a good radiological response

she had total mastectomy and LND:
bifocal residual carcinoma, T1: ILC, 3.7 cm
T2: IDC, grade 2
negative margins, lVSI neg, skin free, nipple free, 0/21 negative nodes with no signs of fibrosis.
HR+, Her2 neg

Do you offer PMRT?

---

Members don't see this ad.

 

[medgator]

It grew on chemo? Odd. More likely I'm guessing as an ILC, it was probably underestimated on initial eval.

I don't see a strong indication for pmrt

 

[Bequerel]

I went to a cme meeting in NYC last year (just using cme money for free weekend trip) and the med Onc speaker from Harvard was advocating no chemo for ilc, even with some crazy case with like 6/15 nodes positive. Not surprising there was no response to NAC. No indication for PMRT. Obviously there would be indications if there were positive margins and perhaps if it were > 5cm. Also, possibly PMRT if T2 TNBC, but that would be a different case altogether.

 

[scarbrtj]

Every LN she had dissected was a potential PMRT indication. So one might say after 21 attempts to give her a reason for PMRT, all 21 were unsuccessful.

 

[BruiservonWillebrand]

Are you sure PMRT is enough...

Please put down the chart and back away from this patient.
Maybe she had an MRI because this was ILC or for the decision between lumpectomy and mastectomy, but if she was going to have mastectomy anyway this was not indicated.
Her PET was not indicated.
Maybe she was trying to get to a lumpectomy so she received neo-adjuvant chemotherapy, but response rate is poor for HR+,Her2- tumors, and neo-adjuvant chemotherapy is not indicated.
ALND on a cN0 patient is not indicated.
PMRT is also not indicated.

 

[w00tz]

Are you sure PMRT is enough...

Please put down the chart and back away from this patient.
Maybe she had an MRI because this was ILC or for the decision between lumpectomy and mastectomy, but if she was going to have mastectomy anyway this was not indicated.
Her PET was not indicated.
Maybe she was trying to get to a lumpectomy so she received neo-adjuvant chemotherapy, but response rate is poor for HR+,Her2- tumors, and neo-adjuvant chemotherapy is not indicated.
ALND on a cN0 patient is not indicated.
PMRT is also not indicated.

Maybe this was multicentric disease and BCS would be contraindicated anyways.

 

[evilbooyaa]

Agree with others, no need for PMRT. Was the second tumor known to be ILC on biopsy? That would better explain the thought process behind NAC - hope to down-stage and pursue multiple lumpectomies (some surgeons consider it for multifocal disease especially in large-breasted women that would have reasonable cosmetic outcome).

ILC is very frequently undercalled on initial imaging including even MRI. But you have a multifocal cT2N0 that is multifocal ypT2N0 s/p ALND. If it was ypT3N0 then I think my opinion would change.

I'm fine with breast MRI in case patient was considering the step above.
PET might have been overkill but I can see a worried med-onc getting it.

I will agree that I am somewhat confused at the ALND - maybe surgeon doesn't believe in AMAROS.

Regardless @BruiservonWillebrand the OP was (most likely) not the one ordering all of those tests and/or involved in surgical planning. Not sure if your statement of 'Please put down the chart and back away from this patient' is meant to denigrate her management from the OP's position, but OP likely did not have any input into this patient's care (or know that she existed) before she showed up post-op, and is asking a good faith question of a concerning clinical scenario (if you just look at the numbers, her ILC grew on chemo).

 

[scarbrtj]

Agree with others, no need for PMRT. Was the second tumor known to be ILC on biopsy? That would better explain the thought process behind NAC - hope to down-stage and pursue multiple lumpectomies (some surgeons consider it for multifocal disease especially in large-breasted women that would have reasonable cosmetic outcome).

ILC is very frequently undercalled on initial imaging including even MRI. But you have a multifocal cT2N0 that is multifocal ypT2N0 s/p ALND. If it was ypT3N0 then I think my opinion would change.

I'm fine with breast MRI in case patient was considering the step above.
PET might have been overkill but I can see a worried med-onc getting it.

I will agree that I am somewhat confused at the ALND - maybe surgeon doesn't believe in AMAROS.

Regardless @BruiservonWillebrand the OP was (most likely) not the one ordering all of those tests and/or involved in surgical planning. Not sure if your statement of 'Please put down the chart and back away from this patient' is meant to denigrate her management from the OP's position, but OP likely did not have any input into this patient's care (or know that she existed) before she showed up post-op, and is asking a good faith question of a concerning clinical scenario (if you just look at the numbers, her ILC grew on chemo).

I certainly almost never have input in a breast cancer patient’s pre XRT pathway before I see them. Sadly. A lot of these breast cancer patients “drive” their care car too more than we might allow in other disease sites.

Soooo... if this were T3N0 and someone were considering PMRT, what LN stations would you cover and how would you “cover” yourself regarding that decision? Don’t shoot me.

 

[evilbooyaa]

ypT3N0 is a reasonable situation to offer PMRT. I would treat CW +/- RNI in a general sense. I would, generally, cover CW, undissected axilla, and SCV. Consider IMC if the ypT3 tumor was medial. Every patient slightly different, requires discussion of risks of lymphedema and some evaluation of patient preference.

cT3N0 without NAC is a true coin-flip IMO (as it has been for decades) in regards to 'need' for PMRT. However, cT3N0 that successfully downstaged to ypT1-2N0 I would generally omit treatment.

 

[scarbrtj]

ypT3N0 is a reasonable situation to offer PMRT. I would treat CW +/- RNI in a general sense. I would, generally, cover CW, undissected axilla, and SCV. Consider IMC if the ypT3 tumor was medial. Every patient slightly different, requires discussion of risks of lymphedema and some evaluation of patient preference.

cT3N0 without NAC is a true coin-flip IMO (as it has been for decades) in regards to 'need' for PMRT. However, cT3N0 that successfully downstaged to ypT1-2N0 I would generally omit treatment.

In this case (0/21 LN+), I would def omit axillary RT.

 

[evilbooyaa]

In this case (0/21 LN+), I would def omit axillary RT.

Very reasonable to do so.

 

[Palex80]

Nope, no indication.