I assume you mean cN0/pN1 here. And isn’t no SLNB the SOC for most low risk breast presentations now. Don’t let inappropriate sentinel LN biopsying ruin a woman’s chance at less toxic RT has kind of been my motto but I’m open to be corrected. Similarly don’t let following the SOC of no SLNB ruin a woman’s chance at less toxic RT.
A lot of peeps happy to give them years of AI though
Yes, this too. There is a substantial number of pT1NX women with a met lounging in the axilla who aren't getting adjuvant RT.
I think where we are headed is you will never know if a 75yo with strongly ER positive low grade is pN1, we won’t care, and we will give them 5 fraction PBI. Have any of you started seeing women (especially 70+yo women) whose surgeon followed INSEMA? Do you let pNX cause a change in RT management?
But if this were possible/true wouldn’t we have seen a signal of increased axillary recurrences, or out of volume PBI recurrences, in IMPORT LOW or Livi?
Well, these patients all had SLNB. And almost all of them were negative.
Correct me if I’m wrong but there was no hint of different axillary recurrence rates in MA20 (treated axilla) vs EORTC 22922 (didn’t treat axilla). No differences in SUPREMO. No difference in axillary recurrence in Z0011. No difference in axillary recurrence with whole breast versus partial breast. No difference in INSEMA.
You are talking about trials where the axilla was surgically staged. This is a different scenario.
Can I say this is fear mongering without being sassy or snarky. Probably not. As Gary Busey says “FEAR… false evidence appearing real.”
Just learned that at least in Europe pNx a contraindication to PBI 🙁
Let's just say, this is an "expert opinion", not definetely something I would follow blindly.Just learned that at least in Europe pNx a contraindication to PBI 🙁
is pNx a contraindication to no RT?Just learned that at least in Europe pNx a contraindication to PBI 🙁
Do you have data to support the statement that positive margins do “not increase the risk for a failure somewhere else in the breast…”? I have looked at some of the older studies and they do not clarify the exact location of these failures. It’s always seemed crazy to me that we go from APBI to whole breast + 16 Gy or higher boost for a positive margins when it seems like you just need to increase the dose locally at the tumor bed/+margin. Wish we had data to back this up
A little crazy. Check.
I wish we did have data to back it up.
Pretty sure the ESTRO HDR or some brachytherapy society has an similar approach in their guidelines. The margin width subtracted from some fixed width. It is a totally rational idea
Wasn’t T1N1 allowed in IMPORT LOW. That’s an evidence base. Assuming SLN+ only, ie the patient did not receive the standard of care (which is no axillary sampling), we are going to allow inappropriate care to allow us to give appropriate care? I think in these cases “damn this poor woman got screwed by her surgeon who made her SLN+ and now her rad onc is all tweaked up to irradiate an order of magnitude more normal tissue in her body.” I presume you’re not going to do ENI on a 70yo lady with a 1cm Gr2 ER+ IDC who has a 2mm focus of tumor in a single SLN. But I shouldn’t presume! What would you do. Again I think the most rational (and probably humane) option, if RT is given, has to be 5 fx PBI. Patient selection and other factors are key; but of course we are talking these low risk/favorable presentations.
Even Z0011 allowed, or prescribed, tangents to N+women absent ax dissection. Combine this (ignoring the axilla) with the trials supporting observation in N- elderly women and it's easy to get to observation in a T1N1 70 yo with ER/PR+ cancer. It's also easy to get to RNI.
Easy? There’s a 5000 patient trial (INSEMA) where cT1N0 were randomized to SLN bx or nothing. About 15% of the women in the bx arm had a LN positive. So women in the no bx group exist in a kind of “superposition” of being node negative or 15% probability of node positive. Of course once the bx is done and a node is positive, the precise state of the axilla is known (Z0011 tells us that a negative SLN bx doesn’t tell us the precise state of the axilla, that’s a different story). But the trial tells us that making the measurement and determining info by sentinel node biopsy does not change the clinical course. So why, since the data is clear, is it “easy” to do RNI for SLN+ T1N1. (Only 8 of the 5000 women in INSEMA had axillary RT/ENI; but no women had PBI.)
Can I make the argument that there is more evidence that RT is effective for arthritis than there is for “high tangents” for breast cancer.
same with clinically node negative group in nsabp 04 who had axilla unaddressed?
pubmed.ncbi.nlm.nih.gov
A never noder? I’m not a Sith. 😉
Have heard enrollments have been slower than expected, but don't think slow enough that it's close to closing.
Any presentation that is N+ and the woman is receiving chemo I apply s'clav field. (With gross ECE I will apply axillary fields.) As we know, the main two randomized trials of RNI (MA20/EORTC 22922) had radiation field similarity only at the IMN 1-3 interspaces and the medial s'clav, and these trials didn't show improved OS or DFS w/ ENI (and MA20, which used axillary fields, showed increased lymphedema risk vs EORTC 22922). As we also know, there are randomized trials showing that the addition of IMNI doesn't improve outcomes, and the IMNs show vanishingly small risks of isolated recurrence in present day or older times, and adding IMNI ups heart/lung XRT exposure quite a bit. As we also also know, there is a meta-analysis showing ENI improves OS, but it's a bit awkward in that the radiation fields are inconsistent in the meta-analysis, and that ENI was shown to significantly kill women in older times, among other things. As we also also also know, the s'clav seems to be a common if not the most common site of nodal relapse in women who have any axillary nodes positive. Finally, as we really truly should know, it's been hypothesized for ~50 years that "Variations in local-regional therapy are unlikely to substantially affect survival," yet we rad oncs keep thinking it will.
I didn't "make it out to be" anything, precisely, that I can recall. However, I would say whatever it is it is likely consistent with what's predicted in the nomograms. To paraphrase Obama, if you like your axillary irradiation you can keep your axillary irradiation.
What about a pN+ scenario where the patient is not receiving chemo? Low oncotype? You're not doing SCV field? If that is the case, rationale?
