Not to derail things, but are people in the US commonly doing chest wall only?
I would also consider in her case if she were inner quadrant (combined with G3, extensive LVSI). Not her, but also for inner quadrant TNBC. Admittedly her completion dissection would dissuade me some given lymphedema risk. Along the lines of the high risk node negative patients who benefited from RNI in MA.20 and EORTC 22922. Not saying that its a must here, but I think it could be discussed if inner quadrant.
~30% risk of Gr >=2 lymphedema here if she's overweight or mildly obese and planning full ENI
according to NCDB patterns, yes. I think if you're giving RT for a positive margin post mastectomy with a negative LND or SLNB, it's reasonable to do chest wall alone
For me, if pT3 is the reason for PMRT, it's pretty much the one scenario I'll do chest wall only. It's also the only scenario I've heard for just chest wall from other folks...but I literally don't have a guess as to how often it's done.
That's very interesting.
Respectfully, I think this is faulty logic. Of course, we probably should never invoke "logic" in a breast discussion. But, in general, recurrence risks after mastectomy are about 20:5:2:2:1 distant:CW:ax:sclav:IMN. And the "1" for IMNs is more like 0.5 nowadays. With or without IMN sampling, we know IMNs have a pretty high involvement rate (up to 20-50%) with ax N+ and inner quadrant location, but an exceedingly low recurrence rate (1% or less) nonetheless. Some back of envelope calcs indicate you must irradiate 1000-1500 IMN stations to prevent one recurrence there. I'm not saying never irradiate them, but to irradiate them and not irradiate the ax/sclav is... well, you know.
Do we mention that the "tumor-to-nodes-to-distant" gestalt has very little to do with the actual behavior/natural history of breast cancer enough? It is a persistent, stubborn illusion...
I'm sure someone has looked, and it's lazy of me to not google, but my simple brain tells me that min 40% of the cells here are triple negative (I did a PhD where I looked at tons of IHC so I get the caveats, but in the end, the way we determine this characteristic is with IHC), and so I wonder how hormone receptor positivity correlates with outcomes, particularly when ER + PR is well less than 100%. As said earlier, oncotype probably important in this context as we treat HR+ high oncotype more like TN.
Ah yeah good point - for me, "chest wall alone" takes a pretty good piece of axillary levels depending on how things shake out. No routine bolus or boost (case by case, never say "never" or "always"). Axilla is basically unavoidable with 3D. Now, if/when we move into more IMRT, that's an interesting debate.
Oh man, ok first:
I'm busting this line out in chart rounds to catalyze a 45 minute argument if it's a slow week.
I *never* vary my tangent height, because AFAIK every time it's been clinically examined (e.g. the RT post-mortem on Z0011 being an example) it's had zero association with ax recurrence rates much less LRC or OS. (Dosimetric examinations or hypothetical extrapolations don't matter to me that much.) Like meme said though, change my mind! *can opened*
Arguing about tangent height is like arguing about abortion.
One thing I think we might all agree on: high tangents or low tangents, selective IMN RT or not, stylistic locoregional RT "tweaks" notwithstanding, we will all think in our own head: "Well... I have not seen any downsides to my approach in my patients, so I must be doing it right!"
Excellent point(s).
Not commonly. Only scenario I would think of is for positive margins not amenable to re-excision in the absence of other risk factors. pT3N0, LVSI, Grade, etc. I would add RNI.
I recommend RNI (meaning Ax I-III + SCV, +/- IMN based on Korean study evaluating primary location) for all macromet pN1a patients, with consideration of omission if a complete ALND has been done and nodal ratio is < 10% (meaning 1/10+)
Exactly what I do .. but wait, I did train there. But happy to rename it The Evil Way
I have no idea if anyone else is calling it "the UPMC way" or if that's just me.
But, but... MA.20?
Trying to figure out how much tangent height contributed to MA20 outcomes would be like trying to figure out how much human farts are contributing to global warming
I can think of no other situation in rad onc where the studies (MA20, EORTC 22922) failed to meet their primary endpoints but rad oncs *still* went on and changed their standard of care for essentially everyone similar to patients enrolled on the "failed" trials. And we aren't talking subtle changes or changes of de-escalation or non-irradiation... we are talking irradiating twice or thrice as much normal "uninvolved" tissue with the standard of care switching (with known side effects in doing so). Still baffles me a bit to this day. (And now we have people justifying IMN RT on the basis of the "failed" Korean IMN trial; post hoc analysis... it's a helluva drug). If only we would have had this much self-beneficial-lying-to-ourselves mentality on fraction-lowering and radiation-omission trials! *shakes fist at sky* *continues reading 'Outliers'*
SpaceOAR is doing its best, ya know
Industry funding will get you everywhere. Doesn't explain rni though
Superior inner quadrant
For "the benefit of the children" I throw shade on IMNs but don't not irradiate them 100% of cases. I wrote these words 21 years ago:
