SLNB, path CR XRT fields

[Reaganite]

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T3N1 patient gets neo then mastectomy with SLNB with a good oncologic breast surgeon (dual tracer, 3 nodes removed, initial biopsy positive node clipped) with path CR in breast and axilla. What fields are you treating?

 

[TheWallnerus]

T3N1 patient gets neo then mastectomy with SLNB with a good oncologic breast surgeon (dual tracer, 3 nodes removed, initial biopsy positive node clipped) with path CR in breast and axilla. What fields are you treating?

This “Practice changing data” says no RT/no fields. As we recently discovered though one of the most important decision points, now, for these such cases is not the pre-chemo factors but rather should I change practice if I don’t have this data in published paper form?

 

[drowsy12]

T3N1 patient gets neo then mastectomy with SLNB with a good oncologic breast surgeon (dual tracer, 3 nodes removed, initial biopsy positive node clipped) with path CR in breast and axilla. What fields are you treating?

This is a clear case of no RT. This is a B51 patient.

 

[HolySmokes]

Agree with omitting RT

 

[StealthTech]

Protons

 

[Palex80]

 

[Reaganite]

This is a clear case of no RT. This is a B51 patient.

I bring up this case only because I'm getting mild pushback from surgeons about blanket applying no RT to any patient who would have qualified for B51. Agree with no RT, but have a surgeon questioning this particular scenario (mastectomy with SLNB only) without the final publication of B51. Would your opinions change in say an ER-positive patient who didn't get dual tracer and <3SLN removed?

 

[TheWallnerus]

I bring up this case only because I'm getting mild pushback from surgeons about blanket applying no RT to any patient who would have qualified for B51. Agree with no RT, but have a surgeon questioning this particular scenario (mastectomy with SLNB only) without the final publication of B51. Would your opinions change in say an ER-positive patient who didn't get dual tracer and <3SLN removed?

So if I’m following this logic, by the surgeon “going light” on the axilla he wants… IMN and sclav radiation (and ax RT, natch) to make up for that?

 

[Reaganite]

So if I’m following this logic, by the surgeon “going light” on the axilla he wants… IMN and sclav radiation (and ax RT, natch) to make up for that?

yeah, some have mentioned 1071 FN rate and potential need for additional axillary radiotherapy in these patients. There are mednet musings on this specific scenario too. Noticed several "prominent" breast rad oncs are still considering XRT to the chest wall/undissected axilla in mastectomy/SLNB patients patients who meet B51 eligiblity and achieve pCR. Just interested in this boards take on this specific issue.

 

[TheWallnerus]

yeah, some have mentioned 1071 FN rate and potential need for additional axillary radiotherapy in these patients. There are mednet musings on this specific scenario too. Noticed several "prominent" breast rad oncs are still considering XRT to the chest wall/undissected axilla in mastectomy/SLNB patients patients who meet B51 eligiblity and achieve pCR. Just interested in this boards take on this specific issue.

I would just muse that in this case, there was not only a pCR in the nodes but also the primary. That’s especially favorable prognostically and makes finding positivity in the 4th through 40th lymph nodes looked at in her axilla (she had three looked at) unlikely.

 

[Palex80]

I bring up this case only because I'm getting mild pushback from surgeons about blanket applying no RT to any patient who would have qualified for B51. Agree with no RT, but have a surgeon questioning this particular scenario (mastectomy with SLNB only) without the final publication of B51. Would your opinions change in say an ER-positive patient who didn't get dual tracer and <3SLN removed?

Fair point.
When we have a patient with cN1 disease, scheduled to undergo neoadjuvant treatment, our radiologists comfirm cN1 with an ultrasound-guided-biopsy of the node prior to systemic treatment. They also deposit a clip in the node. If the patient achieves ycN0 on neoadjuvant treatment, we can the verify on the SLNB-specimen if the initially involved LN was actually removed too, by looking for the clip.
This will surely not solve the issue of "was that the only affected node?", but it will rule out uncertainties, that the initially affected node was removed during SLNB.


The Sentina trial looked into a similar question, published more than 10 years ago.

Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study - PubMed

Brustkrebs Deutschland, German Society for Senology, German Breast Group.

pubmed.ncbi.nlm.nih.gov

Patients with cN1 disease who convered to cN0 after neoadjuvant chemotherapy, received SLNB, followed by axillary lymph node resection (regardless of the SLNB result), this was the Arm C of the trial.

226 patients had a successful SLNB showing ypN0 in the sentinel nodes (median number of removed nodes: 2).
14.2% of those 226 patients (32 patients) actually had positive nodes in the rest of the axilla.

 

[evilbooyaa]

If ER/PR+/Her2- I think still proceeding with PMRT is not unreasonable per subset analysis. If Her2+ or TNBC I would strongly recommend omission in light of B51 presented data, even without full ALND.

 

[Fpg1245]

If you’re going to go light on the axilla why not go light on the primary as well?

I’m still waiting for a non op approach to TNBC and HER2+ BCa. Probably will have done a second residency by then.