pN0(i+), do you treat the nodes?

[Kroll2013]

---

Members do not see this ad.

Dear friends,
I have a 39 yo female diagnosed with a 2.3 cm IDC of the left Breast. she underwent a partial mastectomy with sentinel node sampling. it is a grade 3 IDC, Ki67 30%, 2 LN were sampled, both positive with isolated cells <2mm (i+). LVSI +. she received adjuvant chemotherapy.

i know that according to Z0011, it is justified not to irradiate the nodes.
What is the best practice now, considering her age and the grade?

 

[taserlaser]

For someone like this, unpublished data I saw off of MA20 from one of the author’s talks showed a small kickoff split of curves at around ~5 years or so for a tiny tiny difference in outcomes between i+ and no cells obverved. So the academic institution I trained at tended to treat more often that not “high risk node negative” patients, and the other academic centre down the road did not. Mind you, these patients I think would not have received chemotherapy around my neck of the woods, and instead receive RT. With the chemo, I would probably tend for just breast alone.
Her risk factors right now definitely are age, LVI, and grade. Do we know her hormonal and Her2 status?

So you’ll see a variance in practice I think in for patients who don’t get chemo, with probably most folks here choosing not to treat given that she did. I would also be curious to hear what others think here too, since I have not treated breast regularly for about 2 years or so.

 

[RadOncDoc21]

Dear friends,
I have a 39 yo female diagnosed with a 2.3 cm IDC of the left Breast. she underwent a partial mastectomy with sentinel node sampling. it is a grade 3 IDC, Ki67 30%, 2 LN were sampled, both positive with isolated cells <2mm (i+). LVSI +. she received adjuvant chemotherapy.

i know that according to Z0011, it is justified not to irradiate the nodes.
What is the best practice now, considering her age and the grade?

I’m going to predict that you will have a high number of variable answers. I would lean towards offering at the very least “high tangents” to the area. Without a full lymph node dissection, I think we’re always going to be put in these types of situations. I know there is a risk of toxicity, left sided, young but if it was my relative or friend, I would recommend some sort of coverage.

 

[BobbyHeenan]

I’m going to predict that you will have a high number of variable answers. I would lean towards offering at the very least “high tangents” to the area. Without a full lymph node dissection, I think we’re always going to be put in these types of situations. I know there is a risk of toxicity, left sided, young but if it was my relative or friend, I would recommend some sort of coverage.

I'll vote for this too. I'd probably do "high tangents" here too. Contour level I-II and try to cover most of it with your tangents.

Agree that reasonable opinions will vary here.

 

[Pointless]

Brace for scarb in 3.... 2.... 1....

 

[RickyScott]

I’m going to predict that you will have a high number of variable answers. I would lean towards offering at the very least “high tangents” to the area. Without a full lymph node dissection, I think we’re always going to be put in these types of situations. I know there is a risk of toxicity, left sided, young but if it was my relative or friend, I would recommend some sort of coverage.

in general agree abt high tangents- contour level 1, 2. Lvi is the problem here, not ihc+.

But would probably individualize...
If medial upper inner,could consider treating all nodes and imn, and maybe scv as they would be first echelon drainage. (I would even considering contouring upper imn) If upper outer would block heart.

I once a had young pt who had very superior upper inner medial tumor High grade LVI but negative axilla. I treated scv and upper Imns because “that is where the money is” I felt obligated to treat lower inner breast and axilla, only because it would appear weird to leave them out.

 

[Mandelin Rain]

Brace for scarb in 3.... 2.... 1....

Haha. According to his calculations, the risk of axillary recurrence is actually (-)8% in this case.

 

[scarbrtj]

Brace for scarb in 3.... 2.... 1....

Yes that discussion was fun't. The world has changed after Z0011; that's irrefutable. But imagine a world where MA.20 and the EORTC trials didn't exist as positive or practice-changing trials because, when they were meta-analyzed, none of the "positive benefits" were statistically significant and instead their most significant impact on a patient's health were to cause toxicities. Also imagine a world where you have data that doing RNI can be associated with a decreased patient survival and/or at the very least no better survival. (And everybody, even in the trials, defines "RNI" a bit differently, further muddling the message.) All of this data is counter-intuitive and we all in my opinion wind up whistling past the biology graveyard here. Does anyone think the precipitous drop in breast cancer mortality over the past 50 years has come about due to RNI or no RNI, high tangents or low tangents, IM coverage or no, for our patients? At best radiation oncology's contribution to this decrease has been RT yes-or-no, not RT my-style-vs-your-style.

This is a 39yo lady. The radiation effects can be life-long for her. The best number you can derive for a benefit from applying axillary RT here to improve nodal recurrence rates is about a 1% decrease by adding RT.* That's a number-needed-to-treat (NNT) of about 1 in 100. The converse of the NNT is the seldom-mentioned number-needed-to-treat-to-not-help-anyone-and-only-cause-side-effects... which for axillary RT is about a 1 in 1 chance for every patient you see. Think of that: ~95-99%** of ladies getting this so-called necessary nodal RT are not getting any benefit from it (but as mentioned it might increase their lymphedema risk by 50+% or lung toxicity risk >100%). Back to biology... maybe that's one thing to look at if you INSIST on RNI.

Did she get a Mammaprint or Oncotype btw?

* tongue-in-cheek, in the EORTC trial where <10% of patients got axillary RT and about 45% were N0 and 45% were N1, not doing any axillary RT lowered the axillary recurrence rate by ~0.6%.
** For T1/2 N0i+ patients who get zeo addt'l axillary therapy (ie no axillary RT, no ALND), the rate of axillary recurrence is <<1%.

 

[RadOncDoc21]

Yes that discussion was fun't. The world has changed after Z0011; that's irrefutable. But imagine a world where MA.20 and the EORTC trials didn't exist as positive or practice-changing trials because, when they were meta-analyzed, none of the "positive benefits" were statistically significant and instead their most significant impact on a patient's health were to cause toxicities. Also imagine a world where you have data that doing RNI can be associated with a decreased patient survival and/or at the very least no better survival. (And everybody, even in the trials, defines "RNI" a bit differently, further muddling the message.) All of this data is counter-intuitive and we all in my opinion wind up whistling past the biology graveyard here. Does anyone think the precipitous drop in breast cancer mortality over the past 50 years has come about due to RNI or no RNI, high tangents or low tangents, IM coverage or no, for our patients? At best radiation oncology's contribution to this decrease has been RT yes-or-no, not RT my-style-vs-your-style.

This is a 39yo lady. The radiation effects can be life-long for her. The best number you can derive for a benefit from applying axillary RT here to improve nodal recurrence rates is about a 1% decrease by adding RT.* That's a number-needed-to-treat (NNT) of about 1 in 100. The converse of the NNT is the seldom-mentioned number-needed-to-treat-to-not-help-anyone-and-only-cause-side-effects... which for axillary RT is about a 1 in 1 chance for every patient you see. Think of that: ~95-99%** of ladies getting this so-called necessary nodal RT are not getting any benefit from it (but as mentioned it might increase their lymphedema risk by 50+% or lung toxicity risk >100%). Back to biology... maybe that's one thing to look at if you INSIST on RNI.

Did she get a Mammaprint or Oncotype btw?

* tongue-in-cheek, in the EORTC trial where <10% of patients got axillary RT and about 45% were N0 and 45% were N1, not doing any axillary RT lowered the axillary recurrence rate by ~0.6%.
** For T1/2 N0i+ patients who get zeo addt'l axillary therapy (ie no axillary RT, no ALND), the rate of axillary recurrence is <<1%.

Haha, I stand by my “high tangents!” I figured it’s a straight on the fairway kind of approach. Will anybody ever remember my name, probably not but in a world of social media, that’s not necessarily a bad thing.

 

[Pointless]

Haha, I stand by my “high tangents!” I figured it’s a straight on the fairway kind of approach. Will anybody ever remember my name, probably not but in a world of social media, that’s not necessarily a bad thing.

Seconded.

 

[evilbooyaa]

High tangents or regular tangents. Would not add a 3rd field.