Post mastectomy XRT after distant Mantle (?) Radiation - Anyone ever done this.

[Mandelin Rain]

Have a lady 30+ years out from Hodgkins treatment for which, in part. she received XRT to somewhere above the diaphragm. Of course this was out of state and she doesn't know what health care system it was with, doesn't know how many weeks, etc,... so no records. No dose. No field review. No nothing. Tattoo is between clavicular heads. Not sure what to make of that. Maybe a match line. I'm just assuming she got 45 Gy to mantle though.

Now she's post mastectomy with a 5 cm invasive ductal, with multifocal <1mm margin, and a couple positive nodes. No chemo due to low risk genomic testing.

Who is treating this? I think I'm going to and just omit SCV to prevent potential overlap on plexus. DIBH to fully avoid heart. Kind of a risky play, but I don't like her odds as they stand currently.

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[deleted1002574]

She thin? Can treat chest wall with electron fields maybe and skip nodes altogether? One of the few breast cases that may be suitable for proton evaluation (only one I ever sent had Li Fraumeni Syndrome).

 

[deleted774703]

Have a lady 30+ years out from Hodgkins treatment for which, in part. she received XRT to somewhere above the diaphragm. Of course this was out of state and she doesn't know what health care system it was with, doesn't know how many weeks, etc,... so no records. No dose. No field review. No nothing. Tattoo is between clavicular heads. Not sure what to make of that. Maybe a match line. I'm just assuming she got 45 Gy to mantle though.

Now she's post mastectomy with a 5 cm invasive ductal, with multifocal <1mm margin, and a couple positive nodes. No chemo due to low risk genomic testing.

Who is treating this? I think I'm going to and just omit SCV to prevent potential overlap on plexus. DIBH to fully avoid heart. Kind of a risky play, but I don't like her odds as they stand currently.

Devils advocate: Could you argue that this Breast Cancer was caused by Mantle RT?

If so, should you omit RT this time around?

 

[thecarbonionangle]

Can she just get some chemo? Ideally should get XRT but idk about this situation. She is young and her cancer is from XRT likely and people would irradiate again?

 

[Mandelin Rain]

Devils advocate: Could you argue that this Breast Cancer was caused by Mantle RT?

If so, should you omit RT this time around?

You certainly could, though usually I have seen ones with metaplasia or triple negative or something strange. This is grade 2 ER+ PR+.

EDIT: She is 58 yo.

 

[Mandelin Rain]

Can she just get some chemo?

I think med onc has same hesitation. What did she get before? How many cycles? He got the get out of jail free card with the low-risk MammaPrint, and he was happy to take it.

 

[thecarbonionangle]

I think med onc has same hesitation. What did she get before? How many cycles? He got the get out of jail free card with the low-risk MammaPrint, and he was happy to take it.

but what is their worry that she got some cardiotoxic chemo decades ago? If echo is fine its probably ok no? she will for sure get an AI?

i dont think it makes sense to just treat the chest wall w/o nodes. If you are gonna treat it you gotta treat nodes, she was node+

 

[Mandelin Rain]

but what is their worry that she got some cardiotoxic chemo decades ago? If echo is fine its probably ok no? she will for sure get an AI?

i dont think it makes sense to just treat the chest wall w/o nodes. If you are gonna treat it you gotta treat nodes, she was node+

I was going to do high tangents to catch majority of axilla. Not sure the risk of isolated supraclav recurrence. Probably low. I'm most worried of CW recurrence given size and very narrow margin.

 

[BobbyHeenan]

I agree with your plan (treat CW at least).

Reasonable people could disagree though. 5 cm tumor with < 1 mm margin and > 1 node positive is scary to me.

IT doesn't matter to me what caused the cancer.

 

[Palex80]

I'd treat. I'd be reluctant to treat nodes, because of issues with the plexus.

 

[yeasterbunny]

Agree with above; I'd treat, but stay off heart and plexus. The breast reirradiation data suggests that patients tolerate surprisingly well, even with full dose (45-50 Gy) both rounds. Especially with such a long interval in between.

 

[deleted774703]

Agree with above; I'd treat, but stay off heart and plexus. The breast reirradiation data suggests that patients tolerate surprisingly well, even with full dose (45-50 Gy) both rounds. Especially with such a long interval in between.

True, but prospectively its only early data. Abstract only right?

And none of those cases induced a second malignancy, but was locally recurrent reirradiation?

 

[scarbrtj]

Two things for sake of argument.

Rad onc from ten years ago:
“This is not a PMRT patient.”

By definition this is an XRT induced malignancy.

 

[deleted774703]

Two things for sake of argument.

Rad onc from ten years ago:
“This is not a PMRT patient.”

By definition this is an XRT induced malignancy.

Yeah I wouldn’t treat this. RT already caused 1 cancer in this case.

Seems counterintuitive to treat a RT induced cancer with RT

 

[BobbyHeenan]

Yeah I wouldn’t treat this. RT already caused 1 cancer in this case.

Seems counterintuitive to treat a RT induced cancer with RT

So you’d withhold chemo if she got a chemo induced AML from her chemo for the initial breast cancer, no?

I think it’s very reasonable to withhold xrt. Just don’t completely understand why it matters if this is xrt induced or not. Seems her risk of relapse still > risk of a 2nd radiation induced malignancy.

 

[Mandelin Rain]

Yeah, I don’t agree with with no xrt with a xrt related cancer. Gotta treat the disease you’re seeing.

 

[deleted774703]

Def open to hearing suggestions.

Perhaps I’m more skittish than you in this specific case.

This was a nice article on similar case. For what it’s worth they also did not want to irradiate but did mention some retro series who felt it was safe

Breast Cancer Following Radiation for Hodgkin Lymphoma: Clinical Scenarios and Risk-Reducing Strategies

We review available strategies for screening and risk reduction through chemoprevention or risk-reducing surgery, as well as challenges for management of breast cancer in patients with prior exposure to radiation for Hodgkin lymphoma.

www.cancernetwork.com

 

[xrthopeful]

Yeah I wouldn’t treat this. RT already caused 1 cancer in this case.

Seems counterintuitive to treat a RT induced cancer with RT

Huh

 

[thecarbonionangle]

Yeah I wouldn’t treat this. RT already caused 1 cancer in this case.

Seems counterintuitive to treat a RT induced cancer with RT

xrt induced malignancies actually respond Quite well to XRT, data tells us so

 

[deleted774703]

xrt induced malignancies actually respond Quite well to XRT, data tells us so

Like I said, happy to learn.

Haven’t seen this case personally yet

 

[Palex80]

Yeah I wouldn’t treat this. RT already caused 1 cancer in this case.

Seems counterintuitive to treat a RT induced cancer with RT

Never treated breast angiosarcoma?


You could make a meme out of that

- RT induced cancer cells be like: „Oh look, daddy is back! We are going to have new brothers and sisters!“
- Linac be like: „Not before you are dead.“

 

[deleted774703]

Never treated breast angiosarcoma?


You could make a meme out of that

- RT induced cancer cells be like: „Oh look, daddy is back! We are going to have new brothers and sisters!“
- Linac be like: „Not before you are dead.“

Few times our predecessor tried it, got terrible G3 toxicity. Made them gun shy. Hoping it was a one off

 

[taserlaser]

Bad actors. Often will treat, despite the toxicity.

https://www.redjournal.org/article/S0360-3016(19)30173-7/fulltext

 

[evilbooyaa]

Treat at least CW with high tangents. I get the concerns about re-irradiation in terms of plexus dosing and would like to avoid RNI as much as possible.

The concept that 'RT caused this cancer, therefore we shouldn't treat it with RT' make zero sense to me. The concern is... what exactly? That RT won't be effective? Or that she'll get another RT-induced cancer?
Patient lived 30+ years since her Hodgkin's treatment. If the concern is an RT-induced cancer. Let's give her another 30+ years by radiating with likely very minimal toxicity to the chest wall. She'll be 80-90 by then.

DIBH, High tangents, standard fractionation.