LABC: indication of PMRT after neoadjuvant CT?

[Kroll2013]

---

Members don't see this ad.

54 yo female, diagnosed of LABC: cT3cN0. The breast MRI shows 2 suspiscious axillary LNs, that were not investigated. She received neoadjuvant CT and then underwent total mastectomy with ALND. She had complete pathologic response, negative LN over 22 removed. Negative margins. No secondary adverse features.

 

[njshibby]

cT3c? How big was it prior?

 

[Neuronix]

How suspicious on the MRI and no mention of lymph node treatment response on pathology? To me that's a judgement call as to whether they were involved. I'd radiate if they were over 2 cm, had clear evidence of ECE (I'd get the axilla too if that's the case), and/or treatment response on pathology.

Primary size and histologic type with ER/PR/Her2 status? Assuming negative margins of course. TNBC would radiate regardless. ER/PR+ Her2- right arond 5.0cm more controversial.

For bonus fun: was the primary medially located? If so, could argue for IMNs, especially if you believe the axilla was positive. This is where I'm going to get everyone disagreeing with me again 😉

 

[medgator]

How suspicious on the MRI and no mention of lymph node treatment response on pathology? To me that's a judgement call as to whether they were involved. I'd radiate if they were over 2 cm, had clear evidence of ECE (I'd get the axilla too if that's the case), and/or treatment response on pathology.

Primary size and histologic type with ER/PR/Her2 status? Assuming negative margins of course. TNBC would radiate regardless. ER/PR+ Her2- right arond 5.0cm more controversial.

For bonus fun: was the primary medially located? If so, could argue for IMNs, especially if you believe the axilla was positive. This is where I'm going to get everyone disagreeing with me again 😉

IIRC, NCCN says to treat based on PRE-chemo characteristics in terms of the OP's case.

Neuronix, I feel similar regarding TNBC because of some of the recent studies that have been coming out as well as some of what I've seen in practice. My med oncs tell me of a few recurrences after mastectomy for T1/T2 pts who received chemo alone which unfortunately presented both locally as well as with DM.

http://jco.ascopubs.org/content/early/2011/06/29/JCO.2010.33.4714
http://www.thegreenjournal.com/article/S0167-8140(11)00383-5/abstract

I've used TNBC as a reason to radiate in borderline cases (young pt, large T2 primary, G3. LVI, N1mic etc) but I wish the guidelines would address this further as I am not sure what I would do if I got the referral for a T1N0 TNBC in 29 y/o who had a mastectomy for example.

 

[firewicket]

http://www.ncbi.nlm.nih.gov/pubmed/15570071

Depends on if you really consider those axillary nodes negative. If positive would be stage IIIA.

What is everyone's thoughts on asking for biopsy of these nodes prior to NAC? At our institution we always find ourselves scratching our heads afterwards wishing we had a biopsy to guide RNI and situations similar to this.

 

[medgator]

http://www.ncbi.nlm.nih.gov/pubmed/15570071

Depends on if you really consider those axillary nodes negative. If positive would be stage IIIA.

What is everyone's thoughts on asking for biopsy of these nodes prior to NAC? At our institution we always find ourselves scratching our heads afterwards wishing we had a biopsy to guide RNI and situations similar to this.

I biopsy any suspicious nodes via FNA. Some progressive surgeons will also do a SLNBx at the time of port placement as another option

 

[ramsesthenice]

http://www.ncbi.nlm.nih.gov/pubmed/15570071

What is everyone's thoughts on asking for biopsy of these nodes prior to NAC?

We are quite aggressive. It is now closed, but until very recently we had been participating in NSABP-B51 which randomized patients with biopsy proven N1 disease (FNA or core biopsy required) who then cleared nodes following NAC to +/- nodal RT. Its similar to the above study but included BCT as well as mastectomy patients. Outside of trial, we are pretty apt to treat nodes if they were involved.

 

[napoleondynamite]

Based on EBCTCG survival benefit for RT in node+ I would treat based on the preop imaging if it looked legit

 

[Palex80]

I would treat her.
Chest wall + paraclavicular nodes. I would leave the axilla out. IM-RT is a huge controversy. 🙂

 

[BobbyHeenan]

At our multi-disciplinary breast clinic I STRONGLY push for some sort of biopsy of anything suspicious prior to starting chemo (FNA or some surgeons do the SLNB at time of port). I also ask for dedicated axillary ultrasound to get dedicated axillary imaging (not just looking at the periphery of the breast ultrasound to look for axillary nodes). We would probably try to enroll on the NSABP trial in my practice.

Interestingly enough, the NSABP B-18/B-27 local recurrence predictors paper suggests LRR at 10 years is zero for node positive/T3 patients with path CR at time of mastectomy/ALND. However, there were only 11 patients in this scenario, so the MD Anderson paper from 2004 still is probably the biggest experience and shows the high risk of not radiating stage III patients.

Given triple negative (the Chinese data and retrospective data) suggesting more benefit for XRT, I'm inclined to treat. Off study I would treat very similar to how Palex says above. We'll see what comes of the NSABP trial.