Who wants another Great Breast Cancer Debate?

[pikachu]

71 yo, history of single-lung transplant with T1N1 triple negative breast cancer. immediate surgery (ie no neoadjuvant therapy). s/p full ax dissection (11 nodes) - final path with single positive node and associated ECE.
Would anyone treat axilla in this situation? If it matters the transplanted lung is on the right and the cancer was on the left.

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[scarbrtj]

71 yo, history of single-lung transplant with T1N1 triple negative breast cancer. immediate surgery (ie no neoadjuvant therapy). s/p full ax dissection (11 nodes) - final path with single positive node and associated ECE.
Would anyone treat axilla in this situation? If it matters the transplanted lung is on the right and the cancer was on the left.

Fortunately her axilla's already been treated. So yes, someone would treat the axilla in this situation
I would treat the axilla (just with tangents) assuming it's not microscopic ECE because there has been some rumblings from Z0011 folks that gross ECE has a higher than minimal risk of axillary recurrence. I would not do RNI, just a 3-field: tangents/sclav. This is probably controversial. But her biggest driver of outcome is the node positivity and TNBC; whether one irradiate some axilla or not, or nodes or not, will not affect this 71 yo's survival. Only the systemic therapy she takes will do that, and it will also have substantial affect on the LRR risk prior to the RT you'll give several months from now.
Lung transplant for?...
EDIT: While breast cancer not more common after transplant, aggressive breast cancer is: transplant patients w/ breast cancer have ~40% worse survival than typical non-transplant patients.

 

[pikachu]

Fortunately her axilla's already been treated. So yes, someone would treat the axilla in this situation
I would treat the axilla (just with tangents) assuming it's not microscopic ECE because there has been some rumblings from Z0011 folks that gross ECE has a higher than minimal risk of axillary recurrence. I would not do RNI, just a 3-field: tangents/sclav. This is probably controversial. But her biggest driver of outcome is the node positivity and TNBC; whether one irradiate some axilla or not, or nodes or not, will not affect this 71 yo's survival. Only the systemic therapy she takes will do that, and it will also have substantial affect on the LRR risk prior to the RT you'll give several months from now.
Lung transplant for?...

the transplant was for COPD

what you have suggested is a good compromise but I generally treat my whole-breast-only patients prone- so tangents miss the axilla. In this particular setting, I think minimizing lung dose with a prone plan may be of benefit to the patient - hard to tell if that benefit outweighs any potential downside of omitting nodal radiation.

 

[pikachu]

Fortunately her axilla's already been treated. So yes, someone would treat the axilla in this situation
I would treat the axilla (just with tangents) assuming it's not microscopic ECE because there has been some rumblings from Z0011 folks that gross ECE has a higher than minimal risk of axillary recurrence. I would not do RNI, just a 3-field: tangents/sclav. This is probably controversial. But her biggest driver of outcome is the node positivity and TNBC; whether one irradiate some axilla or not, or nodes or not, will not affect this 71 yo's survival. Only the systemic therapy she takes will do that, and it will also have substantial affect on the LRR risk prior to the RT you'll give several months from now.
Lung transplant for?...

I should add that I agree that the axilla has -already- been treated. my only hesitation was because of the ECE. interesting link - they suggest at the end that ECE in the sentinel node should merit consideration of ALND OR axillary RT...not BOTH, which is reassuring.

 

[scarbrtj]

I should add that I agree that the axilla has -already- been treated. my only hesitation was because of the ECE. interesting link - they suggest at the end that ECE in the sentinel node should merit consideration of ALND OR axillary RT...not BOTH, which is reassuring.

Yeah, you gotta save this woman's life and not hurt her. Radiation will have a long row to hoe on the former but can easily do the latter. Treating IMNs e.g. will def up the overall lung V20, has been consistently assoc w/ lung toxicity in the RNI trials, and would prob nick that transplanted lung a little.

 

[seper]

I have some experience with lung transplant patients... Her relapse rate is much higher than usual due to immunosuppression. She won't be able to tolerate meaningful chemo. So, I would treat generous nodal fields (breast, SCL, +/- axilla +/- IM) while consenting her to elevated risk of respiratory failure due to XRT.

 

[RickyScott]

I could see radiating nodes/axilla +/- IM, I am not sure much benefit radiating the whole breast vs lumpectomy + margin (partial breast) in this case if there is a lot of concern regarding lung,

 

[scarbrtj]

Her relapse rate is much higher than usual due to immunosuppression.

The areas you're thinking about irradiating are still very low risk for relapse and will do nothing to change what is true situation: her risk for death is high due to TNBC, ECE, transplant. I can't IMN without hitting some contralateral lung. I wouldn't put a picogray of dose in that transplanted lung for a Dosoretzian amount of money.

So, I would treat generous nodal fields (breast, SCL, +/- axilla +/- IM) while consenting her to elevated risk of respiratory failure due to XRT.

How generous exactly? Plus/minus is hedging

 

[scarbrtj]

I could see radiating nodes/axilla +/- IM, I am not sure much benefit radiating the whole breast vs lumpectomy + margin (partial breast) in this case if there is a lot of concern regarding lung,

this is prob the right answer but I don't think there'd be many with the intestinal fortitude to do it. It would undoubtedly be best hedge against lung probs in future. I would try extremely hard to keep the ipsi lung V20 to less than 20%, contra lung max dose 0Gy.

 

[yeasterbunny]

this is prob the right answer but I don't think there'd be many with the intestinal fortitude to do it. It would undoubtedly be best hedge against lung probs in future. I would try extremely hard to keep the ipsi lung V20 to less than 20%, contra lung max dose 0Gy.

I agree - including the bit about staying off the IMs. These lung constraints shouldn't be difficult with 3-4 fields

 

[pikachu]

I could see radiating nodes/axilla +/- IM, I am not sure much benefit radiating the whole breast vs lumpectomy + margin (partial breast) in this case if there is a lot of concern regarding lung,

With prone treatment we can get the lung dose quite low assuming the goal is to complete BCT and treat breast only. It is true that she has a high risk of relapse -both local and/or systemic- due to immunosuppression and likely aggressive disease biology. The question is whether the increased risk of lung toxicity in comprehensive nodal treatment is outweighed by the anticipated disease control benefit. Keep in mind that she has already had a full axillary dissection and is being offered chemo.

 

[scarbrtj]

The question is whether the increased risk of lung toxicity in comprehensive nodal treatment is outweighed by the anticipated disease control benefit. Keep in mind that she has already had a full axillary dissection and is being offered chemo.

In the strongest terms possible: no freakin' way. And it doesn't even technically outweigh it, numerically, in the best of cases; another discussion for another thread in an alternate timeline. Vinay Prasad recently wrote: "The wisest of conservative physicians understand and embrace how little effect the clinician has on outcomes. While many may call this frame of reference nihilistic, the conservative clinician sees it as protective against our greatest foe—hubris." Comprehensive multi-nodal RNI in this era is bordering on radiotherapeutic hubris. If the radiation oncologist thinks he or she is (much) responsible for these graphs below... hubris, especially if you think treating the IMNs in this lady who's 71 w/ TNBC and ECE (which is way more a predictor of distant vs axillary relapse) and lung transplanted is going to do anything.

 

[evilbooyaa]

As presented, I do 3-field. I think single node positive with ECE on whether to cover dissected axilla is dealer's choice. Depends on amount of ECE. If microscopic and ALND was done as a full 'packet' of tissue and not individual plucking of lymph nodes (per OP note) then I leave her be. If gross or not a 'packet of tissue' removal then I would likely cover dissected axilla.

Can evaluate IMN coverage but I agree that transplanted lung should see essentially zero dose (except whatever from scatter). No beam entry or exit through the transplanted lung. Where was the primary tumor location?

Boost cavity.

 

[seper]

Cancer patients with major non-kidney organ transplants that I've seen (n = about 10) who need chemo, are usually "are offered chemo", but even those who start it, are dose-reduced, and often drop out due to sepsis... In meantime, disease course is aggressive. There are data on it. This is not a usual breast case.

With prone treatment we can get the lung dose quite low assuming the goal is to complete BCT and treat breast only. It is true that she has a high risk of relapse -both local and/or systemic- due to immunosuppression and likely aggressive disease biology. The question is whether the increased risk of lung toxicity in comprehensive nodal treatment is outweighed by the anticipated disease control benefit. Keep in mind that she has already had a full axillary dissection and is being offered chemo.

 

[Palex80]

I would do SCV in terms of lymphatics, no axilla.
IM is debateable., I would only do IM in this patient if the tumor was situated in the inner quadrants.

 

[RadOncDoc21]

Ugh, this is why I hate breast conferences because depending on the time of day, our strategy and rationale changes.

Unfortunately, there will never be a “consensus.” I would favor adding a SCL but every single post I read had me convinced otherwise.

 

[pikachu]

Cancer patients with major non-kidney organ transplants that I've seen (n = about 10) who need chemo, are usually "are offered chemo", but even those who start it, are dose-reduced, and often drop out due to sepsis... In meantime, disease course is aggressive. There are data on it. This is not a usual breast case.

Very true- it’s not clear that an expanded radiation field will make up for inadequate or no systemic therapy, though.

 

[scarbrtj]

Ugh, this is why I hate breast conferences because depending on the time of day, our strategy and rationale changes.

Unfortunately, there will never be a “consensus.” I would favor adding a SCL but every single post I read had me convinced otherwise.

Very true- it’s not clear that an expanded radiation field will make up for inadequate or no systemic therapy, though.

Raises hand.
"It's not not clear. For women with node positive disease and who don't get expanded fields, their relapse/2nd event pattern appears to be distant>2nd non-breast cancers>local recurrence>contralateral breast cancers>node recurrence. For women with node positive disease and who get expanded fields, their relapse/2nd event pattern appears to be distant>2nd non-breast cancers>local recurrence>contralateral breast cancers>node recurrence. Expanded fields don't change the recurrence pattern frequencies and don't change survival. Effects on 'breast cancer mortality' have been inconsistent. Stronger statistical signals have been seen from toxicity effects than the positive oncological effects of expanding the fields. One modern population-based study saw an OS benefit from IMN XRT... for right-sided patients only. The data are 'consistently inconsistent.' This shouldn't be frustrating or surprising. The Fisherian hypothesis is unforgiving in its prediction of local therapy variations not appreciably changing natural histories. But when it comes to 'consensus'... if you expand the fields, you'll feel successful and there'll be consensus amongst your peers who do so that it works. If you don't expand the fields, this will also feel successful. Just only associate with people who think as you do: best way to reach consensus."

 

[RadOncDoc21]

Raises hand.
"It's not not clear. For women with node positive disease and who don't get expanded fields, their relapse/2nd event pattern appears to be distant>2nd non-breast cancers>local recurrence>contralateral breast cancers>node recurrence. For women with node positive disease and who get expanded fields, their relapse/2nd event pattern appears to be distant>2nd non-breast cancers>local recurrence>contralateral breast cancers>node recurrence. Expanded fields don't change the recurrence pattern frequencies and don't change survival. Effects on 'breast cancer mortality' have been inconsistent. Stronger statistical signals have been seen from toxicity effects than the positive oncological effects of expanding the fields. One modern population-based study saw an OS benefit from IMN XRT... for right-sided patients only. The data are 'consistently inconsistent.' This shouldn't be frustrating or surprising. The Fisherian hypothesis is unforgiving in its prediction of local therapy variations not appreciably changing natural histories. But when it comes to 'consensus'... if you expand the fields, you'll feel successful and there'll be consensus amongst your peers who do so that it works. If you don't expand the fields, this will also feel successful. Just only associate with people who think as you do: best way to reach consensus."

Or agree with whatever the referring docs want.

 

[scarbrtj]

Or agree with whatever the referring docs want.

One of my med oncs, for years now, when a post-mastectomy patient has a positive axilla of any sort whatsoever, will call me up and say, "I need you to radiate this woman's axilla." And then I explain I'll treat her chest wall, and probably not her axilla, and he'll be like "No no no her chest wall is fine. I just need her axilla radiated." He does this especially for the single or double-LN positive PMRT patients. To his credit, it was a stretch for him to even send those for PMRT; but now that he does, he's fixated on the idea that the reason I want to treat them is to XRT their armpits. If I were to say something like, a positive axilla is a marker for recurrence everywhere but the axilla, it would be like this.

 

[RadOncDoc21]

Hey whatever it takes. I get consults for “cyberknife” even though I don’t have one. I stopped explaining the difference in how SBRT can be delivered. So I’ll just happily “cyberknife” that.

 

[Gfunk6]

"CyberKnife" is the "Xerox" of SBRT

 

[evilbooyaa]

One of my med oncs, for years now, when a post-mastectomy patient has a positive axilla of any sort whatsoever, will call me up and say, "I need you to radiate this woman's axilla." And then I explain I'll treat her chest wall, and probably not her axilla, and he'll be like "No no no her chest wall is fine. I just need her axilla radiated." He does this especially for the single or double-LN positive PMRT patients. To his credit, it was a stretch for him to even send those for PMRT; but now that he does, he's fixated on the idea that the reason I want to treat them is to XRT their armpits. If I were to say something like, a positive axilla is a marker for recurrence everywhere but the axilla, it would be like this.

Just tell him you'll be happy to radiate her lymph nodes. Just don't mention that you'll be treating her chest wall as well. People just want you to agree with them.

Just don't bring up data that says women with LN+ disease are still most likely to fail in their chest wall. He probably wouldn't like that... data I mean.