Looks like we have the same breast surgeons
😉
http://forums.studentdoctor.net/showthread.php?t=982617
Based on pN1(mi)(sn), I'd radiate or insist on ALND. If radiating I'd do CW + high tangents. SCV seems reasonable, but I save that for pN1, given that this patient's risk of having SCV disease is likely very small. I base my decision for treatment on multiple series showing worse outcome for pN1(mi) over pN0 such as:
http://jco.ascopubs.org/content/27/28/4679.long
http://www.ncbi.nlm.nih.gov/m/pubmed/17899293/
There is limited prospective data for N1mic outcomes in this setting. There's two single institution retrospective series I know of looking at rates of additional axillary disease when one node is N1mi on sentinel node. But, the rate you get is going to depend on a lot of other risk factors included in some nomograms. Nevertheless, the one prospective series I know of that addresses this question to some extent is reported in this ASCO abstract:
http://meetinglibrary.asco.org/content/32586-65
Looks like a 5% reduction in LRF at 5 years for radiating similar patients. Is that worth further upfront treatment? I hear some physicians saying no, some saying yes, and some saying "well I'll talk about it with the patient."
The other way to approach the question is do you group N1mic with N0 or with N1 with a single node? The answer is that it's somewhere in between... Certainly some are using the mskcc monogram to see the risk of additional disease and making an arbitrary cutoff as to who needs treatment.
I personally feel like leaving potentially non-dissected, non-irradiated disease in the axilla of a pre- or peri- menopausal woman post-mastectomy to be too risky. I'm basically lumping N1mic in with Danish/BC post-mastectomy N1 when I think about the benefits of radiation. But that's a leap of faith, as I understand the histology used in those trials wouldn't have even caught most of today's N1mic disease.
As for chemo, she seems like a good Oncotype candidate. Odds are she's going to be high recurrence score based on grade 3. Regardless of whether you view N1mic as a N0 or N1 patient, there's data for oncotype even in node positive patients (
http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(09)70314-6/fulltext).
