Recurrent Breast Ca Case

[DubZteR]

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Had this case the other day and just wondering what folks on here would do?

56 yo F w/ 2.3 cm grade II, ER/PR+, Her2-, no LVI, left invasive ductal carcinoma treated sucessfully with BCT and now presents 3 years later with a 3.6 cm L supraclav node that on biopsy is consistent with grade II, ER/PR+, Her2- same pathology/histology as previous breast ca. Additional workup shows she has no visible disease elsewhere on imaging. She is healthy otherwise, minimal comorbities. Question is how would you manage this patient?

-Would anyone treat her axillary nodes for microscopic disease? Assuming her previous rads only really took care of level I and maybe some of II two nodes

-Would you give her a radical course of 5500 cGy to the supraclav node? Normally here when we treat locoregional, we give 4500 cGy to the supraclavs but I realize this is a different situation.

-What would you give for systemic treatment here?

 

[Cancerdancer]

Assume she's been assessed by a surgeon?
Also, has this popped up through hormonal treatment, or did she not receive this or stop early?

 

[DubZteR]

Assume she's been assessed by a surgeon?
Also, has this popped up through hormonal treatment, or did she not receive this or stop early?

Not yet assessed by a surgeon for this enlarged supraclav node.

Yes she has received hormonal treatment and progressed.

 

[Palex80]

1. I would not electively treat the axillary nodes. The tangents she had already covered some part of the axilla, so you are bound to end up in trouble, if you try to treat the axillary nodes. You'll have to watch out for preiiiradiated parts of the plexus and may risk arm edema. I am not aware of any data calling for elective axillary treatment in this case.
If I were you, I would look up where the primary tumor was initially located. If it was somewhere high in the upper quadrants, there's a fair chance the tumor drained directly as well to the supraclavicular nodes and not mandatorily through the axillary ones, which would be a further argument for ommitting axillary RT now.

2. You can give her 55 Gy to the node, but I would have a surgeon look this up first. This is still a curative setting (in theory at least 😉 ), so I wouldn't miss any chance to maximize local control. You can probably give 45-50.4 to all of the supraclavicular area and then boost the node, if you think you can spare the plexus through such an approach. Electrons can sometimes be handy for a boost in such a setting, depending on the location of the node. I would also electively treat the lower part of the ipsilateral cervical nodes in this setting (up to the larynx).

3. Switch hormonal treatment (if this has not already happened).



I am actually treating a patient in a similar setting currently as well, the differences being that my patient is 20 years older and has had her BCT including RT more than 10 years ago. It's a very late solitary recurrence of her disease and we extensively looked up, if she didn't actually have a second tumor, failed however to find one.
We are treating more or less like I described, but we are planning to go up to 59.4 Gy with 1.8 Gy/d.
I've done 59.4 Gy to the supraclavicular nodes only once before to a younger patient with an isolated supraclavicular recurrency. She tolerated it well, but unfortunately failed 2 years later with metastatic disease in the bones. She's still in complete remission in the irradiated area and with no symptoms.

 

[Brim]

What was her initial nodal status and what type of treatment was done to the axillla (SLN or axillary dissection?)

Was she on Tamoxifen? Was she on it at the time of recurrence? Did she get chemo previously?

If you can excise safely, do that. Test the node for ER+/PR+/her2.
If grossly excised, give 50 Gy to the SCLV field.
If not grossly excised, I'd give a total dose of 60 Gy to the SCLV node.

 

[DubZteR]

1. I would not electively treat the axillary nodes. The tangents she had already covered some part of the axilla, so you are bound to end up in trouble, if you try to treat the axillary nodes. You'll have to watch out for preiiiradiated parts of the plexus and may risk arm edema. I am not aware of any data calling for elective axillary treatment in this case.
If I were you, I would look up where the primary tumor was initially located. If it was somewhere high in the upper quadrants, there's a fair chance the tumor drained directly as well to the supraclavicular nodes and not mandatorily through the axillary ones, which would be a further argument for ommitting axillary RT now.

-Thanks Palex. As far as not treating her axillary node, would it change your mind if her original tumor were in the lower outer quadrant (lateral)? I'm also not aware of any data for elective axillary treatment but I made the argument that if we electively covered the axillary nodes, this should only increase the risk of lymphedema by 4-7% based on results at our center which may not outweigh her risk of developing more disease? Would anyone give her second line chemo instead assuming she already had AC?

2. You can give her 55 Gy to the node, but I would have a surgeon look this up first. This is still a curative setting (in theory at least 😉 ), so I wouldn't miss any chance to maximize local control. You can probably give 45-50.4 to all of the supraclavicular area and then boost the node, if you think you can spare the plexus through such an approach. Electrons can sometimes be handy for a boost in such a setting, depending on the location of the node. I would also electively treat the lower part of the ipsilateral cervical nodes in this setting (up to the larynx).

-Just curious as to why you would treat the lower part of the ipsilateral cervical nodes in this setting? I'm not really sure what the evidence is behind this but I'm still quite a newbie 🙂

3. Switch hormonal treatment (if this has not already happened).

-would you also add a second line chemo?

I am actually treating a patient in a similar setting currently as well, the differences being that my patient is 20 years older and has had her BCT including RT more than 10 years ago. It's a very late solitary recurrence of her disease and we extensively looked up, if she didn't actually have a second tumor, failed however to find one.
We are treating more or less like I described, but we are planning to go up to 59.4 Gy with 1.8 Gy/d.
I've done 59.4 Gy to the supraclavicular nodes only once before to a younger patient with an isolated supraclavicular recurrency. She tolerated it well, but unfortunately failed 2 years later with metastatic disease in the bones. She's still in complete remission in the irradiated area and with no symptoms.

-sorry to hear about your patient with met dx in the bones 🙁 ... Thanks again for your input 🙂

 

[DubZteR]

What was her initial nodal status and what type of treatment was done to the axillla (SLN or axillary dissection?)

-node neg and i'm not sure about SLN/Ax ..

Was she on Tamoxifen? Was she on it at the time of recurrence? Did she get chemo previously?

-yes, yes, and yes 🙂

If you can excise safely, do that. Test the node for ER+/PR+/her2.
If grossly excised, give 50 Gy to the SCLV field.
If not grossly excised, I'd give a total dose of 60 Gy to the SCLV node.

-node was biopsied and same histology and ER/PR+, Her2- as previous tumor. So it seems like the consensus is to not touch the axillary nodes at this point in her?

 

[Reaganite]

Since SCLAV failure is a harbinger for distant mets, we have offered these patients neoadjuvant chemotherapy followed by RT or surgery based on response. For RT, if patient has clinical CR or residual disease < 1cm, we would boost the original extent of disease to 60 Gy. If >1cm residual, then we take to 66. Initial 45-50 Gy would include entire SCLAV.

Regarding axillary coverage, unless patient did not have axilla addressed previously (either with adequate axillary node dissection or RT) we would not treat given the extremely low risk of axillary recurrence in most series.

UptoDate has a nice discussion on this topic. http://www.uptodate.com/contents/ma...urrence-of-breast-cancer-after-mastectomy#H26

 

[ShirleyT]

No standard answer here. personally, I would probably give the patient second line chemotherapy, then re-assess response. Then I would treat SCV and the entire neck up to the mastoid tip to 50 Gy, then boost to the nodal remnant to 60 to 66 Gy based on response and how hot the plexus got on the plan. Then re-assess for potential neck-dissection after radiation if necessary. I would not radiate the axilla assuming the patient had the axilla adequately addressed the first time around because the risk of axillary failure is low and the risk of radiation toxicity from overlap would be high.

 

[Palex80]

-Thanks Palex. As far as not treating her axillary node, would it change your mind if her original tumor were in the lower outer quadrant (lateral)?

Not really. I would still not electively treat the axilla, provided she was initially nodal negative or something like pN1 (1/15).

I'm also not aware of any data for elective axillary treatment but I made the argument that if we electively covered the axillary nodes, this should only increase the risk of lymphedema by 4-7% based on results at our center which may not outweigh her risk of developing more disease?

One second. Electively treating the axilla in the primary treatment setting may increase the rate of lympedema by 4-7%, that's true.
This woman has been treated to parts of her axilla during her first course radiation treatment, when she received tangents. And now you are bound to cover these same areas, that received something like 40+Gy back then with further 50Gy, if you opt for axillary treatment, bringing the cumulative dose to parts of the axilla to around 90 Gy. This is a totally different situation than primary treatment and may substantially increase the risk of lymphedema. Overlapping doses are the problem here and there is no way you can treat only the so far un-irradiated part of the axilla without getting substantial dose to the already treated part (unless you have protons) 🙂

Would anyone give her second line chemo instead assuming she already had AC?

Not me.

Just curious as to why you would treat the lower part of the ipsilateral cervical nodes in this setting? I'm not really sure what the evidence is behind this but I'm still quite a newbie 🙂

It's just the next level, which may be involved. It's not standard practice, but we do it in our clinic, that's how I was taught to act. 🙂